"Pushy" Veterinary Processes

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

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

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

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

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

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

"Pushy" Rescue Groups

I thought I would look, again, at “push” vs. “pull” systems. Though I have written on this topic before, it can be a little difficult to comprehend. What we are really looking at is when the customer enters the value stream.

If the customer comes onto the scene at the end of the value stream, then we are probably looking at a “push” type system. The product is manufactured and sent to market where, hopefully, there is a customer (or millions!) eagerly waiting for the store doors to open in order that they can purchase said product. We don’t identify a particular customer until the end of the process cycle.This system is typically chock full of wasted inventories along with the warehousing costs to store all of it, not to mention the capital tied up until the first sale is made.

On the other hand, if the customer enters the value stream at the beginning, then we are most likely observing a “pull” system. It is a particular customer order that triggers (begins) the manufacturing of that product, at that time, for that customer. This means relatively little inventory, with little to no warehousing and associated costs.

Let’s take, for example, your basic, “walkin’ down the street” rescue group. They go to the local animal control facility where they pick those animals they think (or hope) can be adopted out later. At some point in the future, they take the animal to a veterinarian to be examined, vaccinated, checked for intestinal parasites, tested for heartworms or FeLV/FIV. If the animal is ill or needs other medical attention, then additional visits may be required. At a later time, the intact animals are returned to the vet for spaying or neutering. The veterinarian is, of course, paid for his/her time, drugs, supplies and knowledge; all of this is an investment on the part of the rescue group. In between all of these steps and at the end, the rescue has to “warehouse” all of these pets in foster homes until a suitable adoptive family can be located, if at all, and recoup their costs by charging an adoption fee. This is a “push”system. The customer (adopting family) only becomes known at the end of this value stream.

If the rescue group utilized a “pull” system, the value stream would begin with the adopting family requesting a certain pet; i.e. a certain species, breed, gender, color, age, etc. and then, only then, the rescue group would scour the local “pounds” until a match was found. The pet would go to the vet for any routine procedures or medical care. It would then be given to its new family for an appropriate adoption fee. No warehousing. Any money spent is basically paid for by the adopting family immediately or, at least, much quicker than in the “push” scenario.

In general veterinary practice is a “pull” system, but there are places where we “push”, also. In my next blog, we will revisit the concept of “internal customers” and “pushy” veterinary processes.

Thanks for stopping by. As always, your comments and questions are welcomed.

Flow (One Piece Flow)

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

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

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

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

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

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

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

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

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

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

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

Standardized Work

Mary is licensed veterinary technician. When a shocky, weak puppy was presented, Dr. A tells her that a PCV and blood glucose is always indicated in cases such as this and should be performed even before the doctor sees the pet. Two weeks later, a similar case presents and Mary performs both tests immediately upon intake. Dr. B, the doctor on duty, pulls her aside and angrily instructs her to never perform any blood tests without orders from the case doctor.

Unfortunately, we have all been witness to such scenarios. The doctors may not realize these type of situations are occurring.  But, the effects on staff can be far reaching.  It engenders feelings on the part of staff of anger, resentment, confusion and loss of confidence in management.

In the Lean method, “standardized work” is our definition of the best way to do work in a way that ensures safety and quality, while driving the best productivity and minimizing delays for the customer. It is the foundation for continuous improvement and employee empowerment. It is necessary for “flow” and “pull”. Standardized work gets everybody on the same page and reduces employee anxiety. When processes are in chaos, they must first be brought into some semblance of stability. What is the best way to do our work? This stability (and ongoing improvement) is achieved through standardized work. Once there has been some degree of order established, then the processes can be improved by applying other Lean methodologies, such as kaizen.

Standardized work is not the same as “standard” work. Standard work might imply written in stone, inflexible, inappropriately detailed or micromanaged. Standardized work is broader in concept. Think in terms of simple algorithms or checklists. For example, requiring the drawing of a blood sample for a routine health profile into a 3 cc syringe as opposed to a 5cc syringe would, in most cases, be too detailed for standardized work. However, in the diagnosing of the cause of a “red eye,” it is important to specify that the Schirmer tear test be run prior to staining the cornea or using any topical anesthetic drops in order to check for glaucoma. “Canned” computer estimates might be thought of as another form of standardized work in that they do not dictate a specific recipe, but suggest considering the need for such drugs or services such as antibiotics, hospitalization, analgesics, diagnostic tests, etc. They act as a reminder.

When we create standardized work documents, it’s important to ask what should be standardized and to what level of detail. What problems are solved or prevented by having standardized work? What goals are being accomplished? The goal is not to have standardized work. The goal is better performance in all dimensions and a better workplace for all. Standardized work is a “means to an end”, not a raison d’etre. As mentioned above, the reason for standardized work is to start the process of improvement, which ultimately is for the purpose of increasing quality and value for the client, the “holy grail” of Lean.

Chaos must be brought under some control with Standardized Work before Lean "tools" can improve processes. Note that the blue dot becomes increasingly evident as abnormal as the process is first standardized and then improved. Lean helps identify problems.

But there are also some important ramifications. Like most of the methodologies that make up TPS, standardized work is designed by consensus with staff.  Consensus means obtaining ideas for problem solving from all stakeholders, including staff. It comes from the mindset that all workers have valuable input, knowledge and skills that are assets to the organization in problem solving. It is a sign of respect for workers. It does not mean that all opinions are valid and must be taken or that each individual gets to do the work however they want. Toyota has long emphasized that standardized work must be created by those who do the work. It is not dictated by managers or experts.

By involving workers in this way, a vital resource is utilized and leads to increased “buy in” and engagement. It improves communication and reduces anxiety on the part of everyone of not knowing what is the correct (preferred, agreed upon) way or doing something incorrectly. It helps insure that vital information is available even if a key staff member is absent or has moved on. Plus, standardized work becomes the basis for a formal, in-house training program and is the foundation for continuous improvement.

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.

Pull Systems

This is the Lean concept that value should be “pulled” from downstream in the value stream by a consumer, backward up the value stream. “Pull” is initiated by a consumer, when the work or item he/she wants or needs it and then proceeds backwards up the value stream. It is the opposite of a “push” system where providers produce a product or service (or information) and then “push” it onto the consumer, down the value stream regardless of whether the consumer wants it or needs it (at that time or at all). This results in much waste, work-in-progress inventory, possibly unnecessary production, increased warehousing and lost capital. All are forms of waste (muda). An example of a “pull” system is filling the gas tank in your car. You don’t typically just put gas in your car at arbitrary times or times scheduled far in advance, regardless of fuel usage. You wait until the gas gauge reads relatively near empty. The gas gauge is the initiating trigger (visual sign). It “pulls” the need to put gas into the car at just the right time, and in just the right amount. The doctor “pulls” the taking of radiographs as needed. Radiographs are not simply taken because a patient has presented to the practice. Supplies are generally ordered on a pull system in a Lean organization, both the restocking from a supplier or distributor to the location, and from a stock room to each point of use, like exam rooms.