Why Lean Is Important: From An Informed Client's Perspective

Today's post comes from Gerald Cronin of the Vivarium Operational Excellence (VOE) Network.

The VOE Network is a worldwide group of Lab Animal and Biomedical veterinarians and experts that have discovered and been successfully utilizing the Toyota Production System, or Lean,  to reduce valuable research costs while at the same time improve research quality and animal quality of life. 

From thier own website:

"Every modern industry and organization has been influenced by the operational advances of the Toyota Production System, the thinking that made Toyota the #1 auto manufacturer in the world.   Decades of research has proven that Toyota's systematic approach to improving operations has tangible long-term benefits to customer service, quality, productivity, adaptability and ultimately to reduce costs."

"The Biomedical Research community recognized these advances over a decade ago and thus began the adaptation of systematic continuous improvement techniques to the Lab Animal Industry.  Consistent with Toyota's philosophy of "sharing what they have learned from over 50 years of experimentation with the world", the Biomedical Research community understood that together, we could improve operations better, faster, cheaper if we shared our knowledge with each other." 

"With over a decade of experience, the VOE-Network was born to help the entire animal care community improve operations through members' experimentation, learning and sharing."

"The Vivarium Operational Excellence Network is a consortium of animal care institutions and companies committed to quality clinical and veterinary research driven by operational excellence.  We are a members-run organization that responds to the evolving learning needs of its members.  Learning spans the organizational spectrum from front-line technicians through Webinars, videos and Lean Belt certification to leadership skills gained from our Leadership Academy events and offerings.  We also look to industry for insights into the best ways to improve operations as well as ways to build a problem-solving culture."

Today's post:

I took my dog to a large Veterinary practice about a year ago and needed to use the restroom.  The restroom was tucked inside the clinical staff area, so I needed to navigate through some hallways to get to where I needed to be.  Along the way, I was able to see “behind the curtain” of this operation.  I was disturbed to see rooms full of medical supplies in random areas, cardboard boxes both opened and unopened piled on top of each other, medical devices stacked on top of unfolded towels and on top of unopened boxes, there was almost zero floorspace for staff to move around.  Random bottles that looked to contain some sort of medication were in random locations.  Then there was the office with piles of paperwork, computer terminals were poking through the mess, almost as if they were struggling for air.
The staff was walking from room to room and asking each other “have you seen the (X clinical item)?”  “Did you call Mrs McGillicuddy or was I supposed to”? “Sorry for the wait, Mr. Cronin, we’re really busy today” and “We will need to schedule your next appointment, we were hoping the machine would be ready today, but it’s in need of maintenance”.

I made it to the restroom and got to see more of the same on the way back. The trip made me pause, as I now questioned the quality of care my dog was about to receive.  I’m also thinking about what I was going to get billed for and why I need to come back. Piles of inventory and random clutter, medications that didn’t seem to belong there, medical devices mixed with cardboard boxes filled with supplies 3-boxes deep.  Machines that should be operational but are not. The red flags were popping up everywhere.  What am I paying for?  Can I trust this clinic?  Who can I trust here? Do they know what they are doing?

You can tell a lot from what you see in a clinic. Maybe some of the judgements are assumptions, but often they are pretty accurate. The telltale signs of disorganization, the questions staff ask each other, the delays, the missed information, the clusters of inventory that often contains expired materials; all give me the chills, no matter if I’m going for my annual physical or if I’m taking my dog to the Vet.   To me, the paying customer, they all tell a story of wasteful processes that I know are built into my bill.

I’ve been a Lean practitioner in healthcare for a few years, watching and helping clinical teams improve their care to the patient in the bed. If they can do more for the patient in a better, easier way, they are all over it.  I now work in the Veterinary world, and I have seen amazing transformations of quality of animal care and improvements to the Veterinary staff quality-of-life by focusing on improving small (sometimes tiny) process that support their daily work.  It’s so exciting to see folks enjoy the teeny challenges of improving their own work. Lousy processes are like “pebbles in your shoe”; workers agonize through the customs and clutter; given the chance, they would stop and remove the pebble to make life better.  Lean thinking does just that for workers, and the animals and their owners benefit exponentially. 

If you ever feel frustrated, rushed, frazzled, buried by complaints, or workers constantly asking questions looking for “common sense’ answers, the prescription may not be buried in a store room or office, but right here, sitting out in the open at no charge to you.  The world of Lean thinking is liberating, and Lean thinkers are eager to share their learnings and experiences with you.  We are here to help you; we’ve all been through the same frustrations and we found the prescription.  Take one small dose daily; you will be amazed at how your quality of life will improve. (My dog is OK by the way).

Gerry Cronin
gmcronin@mgh.harvard.edu
Vivarium Operational Excellence Network
www.voenetwork.com

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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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 .


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Andon Cords and Practice Environmentalism

One of the innovations that Toyota put in place on their assembly lines is the "Andon Cord."

As the picture below illustrates, it is an actual cord (or button) that any worker can pull, which then sounds an alarm and even stops the production line if the problem cannot be resolved quickly. The alarm (blinking lights and chimes) immediately brings (to the gemba) the team leader (supervisor) to address the problem and mutually decide how to fix the issue in real time. If there are recurring problems, the team leader would then help with root cause analysis. This is important so that the same "fires" aren't being put out over and over.

Photo courtesy of Mark Graban

This demonstrates several basic precepts of the Lean philosophy. One, quality is built into the processes. Two, quality (and safety) is part of everyone’s job description. Three, problems are handled where and when they occur. And, four, creating and maintaining an environment of respect and mutual trust between the workers and the leaders.

Now, I am not suggesting that physical ropes be hung throughout the practice, or that alarm buttons be placed in every room. Although, a practice I worked for used a software management program that dedicated one the Function keys so, if pushed, it would alert all of the other computer stations that help was needed in the room where the key was activated.

What I am suggesting, however, is more metaphorical. Our practices need to be a place where anyone feels comfortable speaking up and symbolically "pulling the Andon cord!"

Lean, as much as anything else, is a culture. It is a culture that allows for mistakes and defects to be brought to management and other staff without fear of embarrassment or retaliation. And, to be handled by everyone with a stake in the process. Nothing else about Lean will ever have a chance without this concept being firmly in place and fiercely protected.

I know of a case where a young veterinarian mistakenly amputated the healthy leg of a dog, despite being informed by the surgery techs prior to surgery that this was about to happen.

This veterinarian, however, had very little respect for the staff and had created an environment around her of intimidation and fear. The staff did not feel comfortable in stopping the surgery (pulling the proverbial andon cord) when the patient was prepped incorrectly and placed on the surgery table with the improper limb draped in order to verify if it was the correct leg to remove and everyone was on the same page.

Leadership and management are the practice “environmentalists”; protecting the practice environment from all “trash and pollution", such as egos, jealousy, fear, detrimental internal competition, etc.

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Hear ye! Hear ye!

Please mark your calendars for Monday, May 7th at 1:00pm ET when I will be giving a webinar for KaiNexus with host Mark Graban. The title of the webinar is:

From Pets to Vets: Applying Lean In Unexpected Places

Please join us! You can register here.

and you check out a preview of the webinar here.