"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.

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"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.

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.