A Different Kind Of Rounds: Lean Daily Management

As doctors and veterinary staff, we are well acquainted with the daily ritual of morning or change of shift medical rounds. This is the gathering of hospital staff and doctors to be updated on the current status of all of the patients in the hospital for treatment, and for the dissemination of new treatment orders by the doctors in charge. This is a form of standardized work. It gets everyone on the same page in a routine and timely manner.

Lean Daily Management (LDM) serves the same purpose, but for the operations and management side of the practice.



Each morning, leadership and management go to the gemba to meet with staff of a particular area of the practice to go over that area's board. What numbers are up (and why?) and what numbers are down (and why?). Or, better yet, do the Process Behavior Charts (PBC) of the data show any "signals" or is it all just "noise?" (see also Mark Graban's book "Measures of Success") What countermeasures should be tried? Any new kaizen ideas? What, if anything, can management do to support the staff? Any evidence that standardized work is not being followed?

Sidebar: One of the two Process Behavior Charts above is showing two signals. Can you identify which chart it is and what the signals are?

LDM helps support our progress through that big PDSA cycle called hoshin kanri or strategy deployment. Remember, part of the Act (/Adjust) phase of a successful PDSA cycle is to sustain the results (for now), write new standardized work, scale up if appropriate, and start teaching to the new standard. This brings a new current state, and the next target condition is identified, initiating a new PDSA cycle of improvement.

In the figure above, the wheel has been moved up the ramp (improvement) through A3 thinking and kaizen. But, there are forces in any system that want to undo that which has been accomplished. Some call it entropy; I think of it as organizational gravity. The function of standardized work is to counter those evil forces by stabilizing and sustaining the new current state.

The role of LDM is to sustain and stabilize ("nail down") standardized work as it is currently written. LDM functions as a "checks and balance" for standardized work, which acts as a wedge to help prevent organizational backsliding. LDM is the setting aside of time on a daily basis to monitor for this potential.

So, to recap, standardized work sustains the current state, and LDM sustains the current standardized work.

Lean Daily Management meetings should take 10 to 20 minutes per day. They are typically done in the mornings, however, they need to be a scheduled, daily priority for all involved. Choose the time that’s best for your practice and team.

All extraneous interruptions should be put on hold for the entirety of the time. During the meeting, a staff member from the department or area of the practice, such as the Hospital Care team, quickly reviews the metrics, status of any countermeasures, new problems that have come up, any cross training efforts, new and ongoing kaizen, etc. with management. The staff member that leads the meeting should rotate from amongst the entire team, so that everyone gets the opportunity to lead the conversation and learn.

As is the Lean perspective, management takes on a teaching and mentoring capacity; asking questions to stimulate A3 thinking, encouraging all efforts and practicing servant leadership.

So, Lean Daily Management accomplishes several things:

1. Gets management to the places where work occurs (go to gemba)
2.  Facilitates conversation and consensus building with staff

3.  Demonstrates management's commitment to the staff

4.  Monitors the metrics that support the True North statement and KPIs

5.  Allows time to encourage and appreciate kaizen efforts

6.  Sustains and audits standardized work
7.  Creates increased engagement of the workers

8.  Show respect for workers

Thanks for stopping by. Comments, questions, and suggestions always welcome.

Also, to answer the sidebar questions, the bottom PBC is showing a signal that needs to be investigated. The first signal is the data point above the upper process limit.The second signal is three or four of the last four data being closer to one of the process limit lines than the average. In the case above, the last five data points are closer to the lower process limit line than the average. In fact, it appears that we may be trending around an entirely new, lower average, which indicates that the whole system has changed somehow. Both of these conditions should have been recognized earlier than now, if they weren't. The next step is root cause analysis and formation of countermeasures, i.e. PDSA problem solving.

The Origins of Lean are Not All Japanese

Over the past few years, while discussing what Lean is with people, I have had one or two of them make comments to the effect that they weren’t interested in learning about anything coming from Japan (or any other foreign country!).

Now, while it is true that Lean did come from Toyota via the Toyota Production System (TPS) and Toyota developed this in Japan, much of what originally went into it came from the good ole' U.S. of A.

There were four primary entities from the United States that had an influence on and are responsible for a very large part of what came to be TPS. They are:

1. Henry Ford and Ford Motor Company
2. W. Edwards Deming 
3. Training Within Industry (TWI)
4. 1950s U.S. grocery stores

Henry Ford

The first influence came from Henry Ford's idea of the assembly line and mass production, allowing the increased manufacturing of identical products by several orders of magnitude. 

These concepts included highly standardized parts, which also allowed for the quick replacement of defective parts with identical replacements, which saved time. But, the mindset was still based on inspecting and repairing defects after the fact instead of preventing defects, as Toyota had already been focusing on. 

Not to mention that most of these defects weren't caught until the whole auto had been built, so sometimes it was just as easy to scrap the car altogether. 

But, what the heck! America was victorious after the war and had plenty of returning workers and plentiful resources. What’s a few thousand defective products and the time and labor to fix the situation? Japan was a defeated country with a scarcity of resources, which required them to be more creative.

Toyota, as well as the rest of the world learned from Ford as he started the mass production assembly line. However, they would tweak it quite a bit in the years to come. And, others would learn that Lean applies in environments that are not moving assembly lines.

W. Edwards Deming 

In recent years, a Toyota executive said:

"There is not a day I don’t think about what Dr. Deming meant to us. Deming is the core of our management.”

W. Edwards Deming was an engineer, mathematical physicist, and statistician during the twentieth century, becoming one of the greatest quality gurus of all time. In 1947, Dr. Deming was asked by the United States to go to Japan to help with the census during the post war restoration efforts. While he was there in that capacity, he gave a series of lectures on quality and process control to the Japanese Union of Scientists and Engineers. They eagerly incorporated his material into their thinking. The Deming Prize is still given out in Japan for examples of the highest quality organizations.

The PDSA (or PDCA) cycle is also known as the Shewhart cycle (or the Deming cycle)

From Dr. Deming, Japan and Toyota learned about building quality into the product at the gemba, the PDCA cycle and systems thinking.

Training Within Industries (TWI)

When the United States decided to enter World War II, most all able bodied men were ushered into military service. This left a large deficit in the workforce population, especially at a time when the military industrial complex was gearing up. In order to replace this workforce, women were recruited to fill these positions. Think of “Rosie the Riveter.”

The problem, of course, was that these new hires had little to no training in industry. Because the need was so immediate, the war department started the Training Within Industry (TWI) program.

Training Within Industry was a predominately volunteer program to help get new workers up to speed as quickly as possible. Many of the TWI trainers were loaned to the project by manufacturers, which continued to pay their salaries.

No manufacturing company was forced to utilize the TWI program. They had to request TWI help, and many did. There were also cases where TWI was used in healthcare.

There were four training programs offered at different times called the Jobs programs. These included the Jobs Instruction (JI) course, the Jobs Methods (JM) course, the Jobs Relations (JR) and, later, the Jobs Safety (JS) course. 

The program was very successful and contributed greatly to the United States being among the victors. When the war was over and the United States was helping to rebuild Japan, the TWI programs were exported. Manufacturers, including Toyota, enthusiastically incorporated the concepts into their own cultures. There is still a copy of an original TWI manual in the Toyota company museum. 

Once the war was over, the War Department ended the TWI program, the men returned to their jobs, the industrial revolution was on its way, resources were plentiful, manufacturers didn't see the need of TWI in their companies and interest in TWI dwindled to almost nothing. In recent years, however, there has been a renewed excitement in the old programs and methods.

The TWI Job Instruction (JI) course
This course was designed to teach supervisors how to teach new workers. These people knew their jobs well and had a lot of experience, but many didn't understand how to teach someone else. This course showed them how to dissect the job into its individual steps and provided them with a standard way of instructing on a step-by-step basis. This was the nidus for TPS's standardized work.

Training cards (as shown above and below) for each of the “J" courses were given to students to constantly refer to when dealing with their workers at their jobsite. This was necessary to protect the uniformity and integrity of the material throughout the project.

The TWI Job Methods (JM) course 

Job Methods taught how to improve the work being done. It was the impetus for kaizen or continuous improvement.

The TWI Job Relations (JR) course

The Job Relations course instructed supervisors how the deal with interpersonal relationships and conflicts. Toyota's commitment to the respect of workers and people came from this information.

These early concepts eventually evolved into Toyota's Improvement Kata and the Coaching  Kata. These are the standardized work of how managers and supervisors teach and mentor their direct reports.

1950s United States Grocery Stores 

Toyota executives who had come to the United States to observe and learn were intrigued by the way our grocery stores replenished their shelves at night with only those items that had sold that day. By the next morning, when the store reopened, the shelves were full for customers to purchase and the cycle repeated. 

Very little inventory was kept in the back of the store which cut down on costs to warehouse a large inventory and the capital tied up in that merchandise. All of this appealed to a small company in a small, recovering country. Just-In-Time thinking was born from this U.S. grocery store concept

While there is definitely an Eastern philosophical hue to the Toyota Production System, the roots of much of the mindset, especially what we would consider the major concepts, originated from the United States. But, keep in mind that Toyota is not the same as every Japanese company. They've worked hard to create a special culture -- they've been willing to learn from other countries. How about you?

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https://www.measuresofsuccessbook.com

Thank you for stopping by. Comments always welcome.

The Law of Interconnected Waste

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

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

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

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

The Law of Interconnected Waste

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

What frustrates you about your job? 

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

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

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FYI: I am writing a book!

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


Thank you for stopping by. Please tell your friends about this blog. Remember, comments are always welcome.

Lean Self

One of the aspects of the Lean methodology that I appreciate most of all is the breadth of its  application. Lean is applicable to manufacturing, retail, service businesses, professional associations (Nudge, nudge AVMA!), human healthcare, dental practice and veterinary practice. It can even be extrapolated to one’s own life.

One of my extended family members is going through a rough time, as we all do on occasion. She came to us for some help. Since I naturally think and problem solve with a Lean mindset, I took this approach. Via guided questioning, we went through considering her problems, as I would with a practice problem.

True North

As with any Lean application, the first step is to define the ideal state: our ‘True North. If you were perfect, what would that look like? What areas of your life would you choose to define that perfection? What would be the focus areas? These might include such areas as spiritual ideals, physical ideals, financial ideals, relationship ideals, career ideals, etc. Pick four to six to work on at this time (or even just one!); choosing too many will be overwhelming and spread your work too thin. Create a True North statement in writing. Refer to this document often.

The Current State

Now that you have some conception of where you want to go, you need to honestly define your current state. Where are you right now in each of your focus areas? In an organization, this would be facilitated by going to the gemba with all of the stakeholders (line workers, supervisors, managers, etc) present, in order to observe what is really occurring in the Value Stream and, perhaps, drawing a Value Stream Map. Your gemba is deep inside you. It is your true self, warts and all. No preconceived ideas, no masks, no ego. What is the reality on your “shop floor?” Who are your stakeholders? Consider spouses, good friends, clergy, close colleagues, doctors, advisors. Write down your current situations.

Identify the Gaps.

At this point, you know where you want to be, and where you are in your focus areas. What are the differences or gaps? For example, you know you would like to be at some ideal state financially, and you know where you’re at currently. What is the difference between these two states? These are the problems you need to solve now. Write these down for each of the focus areas.

Root Cause Analysis (5 Whys)

Take some time to think about this step. Why are these gaps present? How did they come about? Why did this reason occur, and why did it happen? How did it happen? Ask enough times that you feel you have identified a root cause. This is important because, until the root cause is found and dealt with successfully, it will continue to be a problem. Notice I didn’t ask who was to blame. Try to concentrate on the systems, biases, prejudices, emotional needs, habits and the like. The idea is to deeply understand how this issue came about. It’s not because you are a bad person. We all are damaged in some way and have shortcomings,but how did these root causes contribute to your current state? Talking with your stakeholders may help.

Design Countermeasures

Now it is time to actively try to remedy the gaps: the problems. In each of your focus areas, what can you do to get even a little bit closer to your ideal state? Remember, though, your ideal state is perfection, and that is not realistic. There are always going to be gaps (problems), but with patience and persistence, you can get very close, greatly reduce your stress and frustration, and greatly increase your happiness, confidence and self-actualization.

Pick the low hanging fruit. Start with the easy stuff. Rack up some small successes that will then lead to greater momentum to tackle the bigger stuff. Focus on baby steps.

These countermeasures are experiments. After the trial period, evaluate the results. If they didn’t work out as planned, reflect on why and how, then tweak the experiment and try again. Try not to get disheartened. Lean is a journey. There will always be experiments to try.

If they do produce gains, then reflect on this, also. Why did this experiment work? What did you learn about the situation, about yourself. Can this same idea or principle be utilized in another aspect of yourself? Sustain this new you and rewrite your new current state. Congratulations!

5S

5S is one of the “tools” in the Lean system. It stands for Sort, Straighten, Shine, Systematize, and Sustain. It typically is used to reorganize a physical space, such as a surgery room, exam room drawer, office. It is used to decrease confusion, wasted time hunting down instruments or tools, and increase visual management.

Are there aspects of your life that could benefit from eliminating “garbage,” reorganizing, and/or prioritizing? What about faulty thought processes, biases, relationships, habits, wasted resources, beliefs?

Kaizen

Kaizen means continuous improvement. There is no set amount that is required, only that we try to be better tomorrow than we were today. There is no punishment if we are not successful on every attempt. We just try again. Again, baby steps. As stated above, Lean is a journey, it is a philosophy, it is a mindset. It is lifelong. The process of defining our current state, identifying gaps and experimenting will never end. But, success will come, if only one millimeter at a time.  “Patience, Grasshopper”!

Final Note

I am not speaking from any ivory tower. I struggle with all of this from time to time and have for most of my life. I, too, am on a journey; a work in progress. Veterinary medicine is not easy.  Veterinary practice management is even harder. I have started a practice and been a solo practitioner for over 30 years (for two of those years I owned and operated two practices), merged practices, worked for a corporation and three other employers. I have stayed awake many a night worrying about my business, my family, my health and my faith. I have experienced complete ‘burn out’ and come out the other end. My goal is to attempt to be better tomorrow than today. None of us are responsible for saving the world, but we are required to participate. Success, in my humble opinion, is to leave this world a little better for having lived here. A Lean mindset supports this effort.

Thanks for stopping by. Comments always welcome.

A Lean Staff Meeting Micro-experiment

The Lean philosophy is built largely around the concept of problem solving and continuous improvement (kaizen) by involving the workers who do the work on the floor (gemba) day in and day out. The idea is to foster and coach (working together) problem solving with them (bottom up), rather than telling them what to do and how (top down). Kaizen is the essence of what we strive for when we build teams or imagine when we use the term “teamwork”. 

The results of all of this are:

1. Many vs. a few minds working to solve the problem.
2. Identifying more problems.
3. Better determination of the root cause(s) of the problem(s).
4. Fosters the Lean concept of a leader/manager being a teacher as well as a supervisor in problem solving.
5. Shifts some of the frustration of management off our "plate" (without losing responsibility).
6. By involving staff in this process, it shows that we value and respect their input.
7. Engages staff in the practice.
8. Increases their value to the practice. Their value appreciates over time.

So, with all of this in mind, try this micro-experiment with your employees (team) at your next staff meeting by taking a more Socratic approach to problem solving (teaching through questioning rather than lecturing).

The Micro-Experiment

• Chose or a elicit a small, non-crisis problem to work on.
• Communicate that this is a safe environment and a "Judgement free zone.” Everyone is intelligent and has ideas to contribute.
• Place three coins in front of you. You are allowed three declarative statements during the staff meeting. If you make such a statement, then remove a coin. All other statements need to be in the form of open-ended questions.
• Think in terms of system failures, not people failures.
• Ask lots of “Why?”s, “How?”s and “What makes you say/think that?”s, not “Who (is to blame)?”s
• No leading questions like “Don't you think it would be better to do _______?” You are not trying to 'manipulate' them into arriving at a solution you've already decided on or simply making it seem like they are participating. This is truly listening to their ideas and honestly involving them in finding possible solutions through concensus (nemawashi).
• Praise participation.

Remember back to when you were learning how to diagnose and what questions to ask and how? Formulating a list of deferential diagnoses and, then, trying to arrive at a definitive diagnosis. It is basically the same process that you are trying to teach your staff about, except instead of a pet with a problem, we are dealing with a practice system, process, flow, and/or communication problem.

It won't work perfectly the first time. This is completely different than how most staff meetings are conducted. Look for small successes and then build upon them. With enough coaching and practicing, one day your staff may identify a problem, find its root cause and decide, together, on a viable solution to try, collect the results and plan the next step with little more than oversight involvement from you. Can I get a “Hallelujah!”?

Let me know how it went. Did your staff surprise you with their deep understanding of the issues? Were they more creative than you expected? Did they have a more realistic perception of the actual problem and root causes than you? How difficult was it for you to teach by asking questions? What did you learn? What would you change the next time? Could you cut back to two coins? One?

Thanks for stopping by. Please tell your friends, staff and colleagues about the blog. Comments and questions always appreciated.

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.

An Interview with Samantha Parrett: NC State Vet Hospital's Dive Into Lean

I am especially pleased to present this edition of leanvets.com for a couple of reasons.

1)  It is the first podcast for me. Hopefully, others will follow in the future as subject material arises. I debated whether to present this blog as a written interview or as a phone interview. Mark Graban, my “partner in crime” for this thing, convinced me to try a podcast and said he would set it up, which he did. Thank you (again), Mark. (This is also being "simul-blogged" on Mark’s wonderful site, LeanBlog.org). I am so glad we did it this way. I want everyone to appreciate the enthusiasm and confidence about this Lean veterinary success that Samantha brought to the interview, which wouldn’t have been so apparent had we done this in a written, email format.

2) This references, to my knowledge, the first published report of the Lean philosophy and methodologies being applied in the veterinary practice arena. AND… it was very successful.  It has been very difficult trying to educate my profession on the merits of Lean. We’re a stubborn lot, at times. “It may work for building cars and even for human hospitals, but this is veterinary medicine. We’re different! Show me the proof it will work in our profession.”, everyone would say. Well, here’s at least one report that indicates veterinary medicine can benefit from Lean, the same as everyone else who has made the commitment to give it an honest trial.

Our guest today is Samantha Parrett. She is the Director of  Business & Administrative Services for North Carolina State Veterinary Hospital. I first came across NC State’s story, “NC State Vet College Dives Into Lean,” last summer while Mark and I were preparing our lecture for the 2016 TVMA Convention and Expo. I have been waiting eagerly for the opportunity to learn more ever since.

There are several points I would like to draw your attention to. 

First, is the enthusiasm and conviction that comes from trying Lean and experiencing the success that can be realized from Lean. 

Second, Sam mentions many of the Lean concepts and “tools” that we have tried to explain here at LeanVets.com. This demonstrates the “real world” applications of these methods. 

Thirdly, the problem of getting more of the surgeries performed during the normal business hours which had been unsuccessfully remedied for a number of years, finally found some success through Lean. 

And lastly, the positive effect the Lean mindset has had on the staff, doctors and, even, students at NC State Veterinary Hospitals. Lean works...even in veterinary medicine!

Thank you for listening. Here is Ms. Samantha Parrett’s interview.



To read a transcript of the interview,  click here.

A3 Reports

A3 reports are the written documents that succinctly record the PDCA cycle problem solving effort, often providing a bit more structure than the four steps. The thought process and steps are very similar to the Practical Problem Solving method. This is sometimes called “A3 thinking.” The PDCA thought process is more important than the specific A3 report format.

The name A3 comes from the international size of paper that’s approximately 11 by 17-inches (in landscape orientation) traditionally used by Toyota and Lean organizations for these reports.

The left side of the A3 is for the Plan step of PDCA. It should include a title, a statement of the problem and a description of the current state. This side is filled out with such information as facts, graphs, charts, key performance indicators, value stream maps and 5 Whys root cause analysis, to name a few. The fact that the Plan step takes close to fifty percent of the entire report is an indication of the importance Toyota places on planning.

The right side of the document contains the Do, Check and Act steps of the cycle. This side might contain the implementation plan (along with the “who”, “what”, “where”, “when” and “how”), the future state value stream map, a short cost/benefit analysis, the result of the implementation plan, the root causes that were eliminated (or not), the changes in policy and procedures (the new standardized work) and a date to revisit the issue in order to continually improve.

PDCA (PDSA) Cycle

We're all familiar with the diagnostic and treatment process. First, we collect as much subjective and objective data as possible. Then, we formulate the tentative diagnosis. Next, we test our diagnosis by prescribing a series of drugs, surgeries or other treatment modalities. If the patient responds, then we continue the course, usually at home with drugs we dispense and instructions for the client. If the patient does not respond, we seek new data and/or formulate a new treatment plan and try again. This process is based on the scientific method of problem solving.

When we have a problem or a question, we design an experiment, we evaluate the results and then we formulate a conclusion. The PDCA cycle is also based on the scientific method. It stands for Plan, Do, Check and Act. It is the Lean method of diagnosing and treating problems at the gemba. 

Created by Walter Shewhart at Bell Labs in the 1930s, it was introduced to post World War II Japan by W. Edwards Deming. It is also known as the Deming Cycle or the Shewhart Cycle. (Some refer to it as the PDSA cycle; Plan, Do, Study, Adjust).

Everyone at Toyota, from executives to managers to floor workers, is taught, understands and utilizes the PDCA cycle. It is a methodology to deeply understand the reasons of the problem(s); to discover what is known and what is unknown. It helps to propose and test countermeasures based on workplace observation, data collection, and consensus from all stakeholders and to evaluate the results of the test. In many workplaces, people “know” the solution and are afraid to (or are unwilling to) admit that their solution didn’t really work out in practice. The PDSA process emphasizes learning both on an individual and an organizational level, and continually improving systems and processes. It requires humility and a scientific spirit - again, one that should be familiar to those in veterinary medicine.

Plan
The plan step involves the critically important step of defining the problem. Instead of talking about problems in an office or conference room, this step should take place at the gemba as much possible, with all stakeholders present, so the problem may be observed where it occurs, when it occurs, and as it occurs. It is also during this step that any other data such as costs, charts, statistics, 5 Whys analysis results, current value stream maps, etc. are presented.

Based on all of this information, a team might propose some potential countermeasures to discuss, test, and evaluate. 

Do 
In the do step, we do an initial test of the proposed countermeasures as small experiments of change. If we have an idea, we might test it first in one exam room or one office, instead of rushing to implement something throughout the organization. Doing a small test of change helps mitigate and minimize risk. That way, if the change we test turns out to not actually be an improvement (or if it creates unintended side effects), less harm is done. If the initial test of change is promising, we can move forward in the area and spread the improvement to other areas.

Check (Study) 
At this point in the cycle, we evaluate the initial results of our countermeasures and compare them with our hypotheses and expectations. Did we accomplish our objectives or fall short? Were there any unexpected results? What did we learn along the way?

Act (Adjust)
If the results are positive, then we can more formally implement the new changes, write new standardized work, train others, and sustain. If the results have fallen short, adjustments are made, and the PDCA / PDSA cycle is repeated with new countermeasures.

Root Cause Problem Solving and The 5 Whys

Do you ever feel like you’re playing a game of “Whack-A-Mole?” The same problems, previously thought to be solved, keep popping up in different areas of your practice at different times. One of the reasons may be that the root cause of the problem has not been identified and dealt with effectively. Lean offers a number of solutions to this situation.

Toyota uses a method called “Practical Problem Solving” or 8-Step Problem Solving, that provides a structured way to investigate and solve problems.

These steps are, as mapped to the PDSA cycle:

Step #                      Step                         PDSA Phase
1                  Clarify the problem              Plan
2             Break down the problem
3                   Target setting      
4               Root cause analysis
5          Develop countermeasures
6       See countermeasures through        Do
7  Monitor the results and processes      Study
8   Standardize successful processes      Adjust

In step 4, one method for root cause analysis is called “The 5 Whys,” which suggests that you ask “why” five times, sequentially, in order to find the root cause.

Why does that problem occur? Why is that? We keep drilling down deeper, rather than just answering the original why five different ways.

The number five is somewhat arbitrary - it’s not always five whys that are required. The idea is to ask enough times to get to a root cause or causes, to get beneath the surface of a problem. Once suspected root cause(s) are identified, countermeasures can be tested and, if they are effective, standardized work can be updated or written to prevent recurrence. It is important that this take place at the gemba, where the problem occurs, with all stakeholders present in order to build consensus about an appropriate countermeasure to test.  If, at this point, you continue to have recurrences of the same problem, then it’s possible that the correct root cause was not identified, or there’s a different root cause this time, or standards that have been put in place are not being followed.

For example, at a large animal veterinary clinic, there was a hydraulic rotating machine that was used to turn cows on their side for treatment. One day, there was some hydraulic fluid on the ground near the machine. The tech noticed this and, instead of just cleaning up the grease, she stopped to investigate. We can start asking why:

Why was there fluid on the ground? Because the hydraulic cylinder had stopped working.
Why had the hydraulic cylinder stopped working? Because the filter was clogged.
Why was the filter clogged? It had not been changed in a long time.
Why hadn’t it been changed in a long time? There was not a standardized work method for doing so. 

There were not clear roles and responsibilities, nor was there a standard changing frequency.
So, instead of just putting out the fire and replacing the filter, a Lean organization would look for a more systemic cause and countermeasure. Not having standardized work could have caused the machine to fail in a catastrophic way, possibly harming an animal or a tech. Just replacing the filter would not have fixed the process in a root cause to prevent the same problem from occurring in the future. Asking “why?” and digging deeper allowed the tech and engineering to come up with a better solution.