A Response To a Comment About My Post "Lean Self"

Last month, shortly after my blog on the “Lean Self”, my friend and mentor Mark Graban posted a comment to that blog. This was unusual.  Usually, Mark emails his questions and points of concern to me after receiving my final draft of the blog post, but before I publish the final, final draft. His questions sometimes come from sheer confusion about what it is ‘that I am really trying to say’, but many times it is his way of teaching in the Socratic (and Toyota) method. That is, rather than lecturing, asking the student a series of questions that lead the student to discovering the answer or reflecting deeper on the subject. Occasionally, I am not sure which it is.

I have decided to answer in another blog post, rather than a reply to the comment that may go unnoticed.

Mark comments:

Thanks for sharing this, Chip.

I agree that having a personal “true north” and understanding your own “current state” can be beneficial.  I don't quite see how to apply the idea of a “value stream” though. What is “value?” How does it flow? How do you see that connection in one’s personal life?

Mark

Here is my response.

Mark, thank you for your comments. Please forgive my tardiness in replying. I have been recovering from a little bit of surgery.

Your questions have caused me to re-evaluate my premise as regards extrapolating the Lean mindset to the “self.” As they should.

What is ‘value’ in this context?

Another way to arrive at an answer to this question is to ask, “What is really important to you in healthcare?” Or, “What is really important to you in a car?” For the “self” it would be, “What is really important to you in your life?” I think (hope!?) for most people it would be “contentment.” To be contented financially. To be content at work. To be content in our relationships.  To be content with ourselves. The Hebrew word “shalom” is generally translated as meaning “peace.” And it does, but it is the peace that comes from being “whole” (content spiritually, physically, emotionally, psychologically); not having excess or being destitute, but from having enough or being grateful with what you do have.

Part of the Lean definition of “value” is that the customer be willing to pay for it. If you are not willing to put a price on what you want, it doesn’t really hold any value. This holds true for the “self”, also. But, it doesn’t necessarily mean money. It means doing the hard work of honest self reflection, letting go of false assumptions, admitting mistakes, mending relationships, simplifying, budgeting, pushing back the ego, stepping out of the forest and,then, prioritizing and starting, somewhere, on a lifelong journey of improvement.

What is the “value stream’?

The Lean concept of the “value stream” requires, amongst other things, a provider, a customer and a “gemba” (the place where the work actually occurs). Unlike other applications of Lean where the provider and customer are separate entities, for the “self” they are the same, us. And the “gemba” is our hearts and minds.

The steps we go through in our hearts, minds and lives to get whatever value we get is the “value stream”. Whether that process results in contentment or “dis-ease” in a particular area of our life depends on how much muda (waste, i.e. faulty thinking, biases, rewritten history, skewed priorities, energy vampires, B**l S**t, etc.) is embedded. Graphically representing this thought process produces a “value stream map”

For example: I must be perfect →  I burned the turkey → I’m a bad cook → I’m a lousy wife → I’m a bad person.  Not good “flow.” Lots of bad processes and “trash.” What’s the value here?

Note that using 5 Why might take you back through this process. For example:

     Why are you a bad person?  Because, I am a lousy wife.

     Why are you a lousy wife? Because, I am a bad cook.

     Why are you a bad cook? Because, I burned the turkey AND I must be perfect!

BINGO!! A possible root cause. The false belief that “I must be perfect!”!

Now, to be able to map this current state value stream may not be easy and it may require the help of “stakeholders” (others who have our best interest at heart). And, just as in any other Lean application, finding the “waste” in order to produce a better future value stream will work best if our “stakeholders” are given access to our gemba and are present; if we are open, honest and communicative about what is going on inside of us and in our lives.

Thus, I think the Lean concepts of value, true North, gemba, current value stream, future value stream, A3 thinking, 5S, 5 Why and kaizen are just as valid working on improving ourselves as it is in improving manufacturing, service industries, healthcare, etc. for the customer- us!

My First Time with Kaizen and Value Stream Mapping

I was recently looking through the documents and photos on some old laptops when I came across photos I had taken when I was just starting to read and learn about the Toyota Production System (TPS) or Lean.

I don't remember how I first learned about TPS, but I do remember that it hit me on such a deep, intuitive, "soul" level that I was instantly and forever transformed. Lean had me at, "Greater value for the customer, better use of resources, less waste and more respect for workers!"


First Kaizen

It always intrigued me that a single groomer could bath, dry, clip, pluck ears, trim nails, and brush out a dog by themselves. In our veterinary hospital, it seemed to require two vet assistants to handle these same dogs when it came to performing a complete annual examination including vaccinations, glaucoma check, a routine blood profile and Heartworm test.

Same pets, same employee skill.

The difference, it appeared to me, was the specialized grooming table with a grooming arm and its ability to restrain the pet with both a neck leash and a flank leash. Could the same table be used in our hospital to allow a single vet tech to work with a single dog, freeing the other tech to work on a different dog at the same time, thus doubling our flow and production?

I borrowed a table from the grooming salon adjacent to our hospital and we experimented.

Long story short, it worked most of the time. It didn't work for the very fear aggressive dogs (they still required two staff for safe restraint) or dogs too big to fit on the table, and, of course, cats didn't cooperate at all. But, the majority of our canine patients were less than 25 pound and friendly, and cats made up only about thirty percent of our practice. Any time savings got all of us finished earlier.

Experimenting with a grooming table for patient treatments

Maybe treatment tables should come equipped with a grooming arm!

The neck and flank leash in action. 

Based on this experiment, we were able to come up with a system to work single handedly with larger, good natured dogs.

I eventually attached rope cleats to the outside of the cage doors to make it easier to tie and release the leashes.

One staff could perform everything needed for our comprehensive annual exams including injections and blood draws.

First Value Stream Map

After working out the grooming table kaizen, we decided to map the Comprehensive Annual Drop-off value stream. Using ‘Post It’ notes would have made the process of optimization easier, but we used what we had available (this white board).

Most important is identifying all of the value producing steps, non-value producing steps and times for both.

I don't remember, but I think this was the current state map.

To create the future state map, steps were arranged to allow some to be performed in parallel rather than in series.

Lean is about doing. Start small. Start cheap. But, start! And, get your staff involved. Lean is about deeply understanding, learning and improving as an organization.

What kaizen could you experiment with? What value stream could you map and improve? Let me know and thanks for reading.

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.

Value Stream

 The value stream is the overall high-level sequence of steps necessary to take a product or service from start to finish (and the delays that occur between steps). A value stream is the “end to end” process, as opposed to just looking at one department or one function.  For example, it might be all the steps necessary to take an animal presented with an illness to a condition where it is healthy enough to go home. Ideally, each step should move the product along towards that which the customer values, and be devoid of any waste. Value stream thinking helps us break down silos that interfere with delivering value to the customer.

The current state map is created by going to gemba with all stakeholders present in order see and record all the steps (and delays). Then, all unnecessary waste is identified and removed. Finally, any steps that can be performed concurrently, combined or need to be rearranged are changed in order to  create the future state map.

Organizations create value stream maps to help people understand the big picture and how to improve things systemically. A current state map documents how things are today, while a future state map is used to create a vision and a plan for an improved system.