Lowering the River

Certainly, there is not a lot of good that comes out of a worldwide pandemic such as Covid-19. But one bright spot of it is that it has forced every aspect of life to be rethought, reimagined and re-engineered. Many of the things we thought were so necessary to the way we work and live may, in fact, be much less important. Coronavirus has made many of us innovate, improve, become more agile. It has triggered a rapid evolution of our systems and processes, much of which will become the new normal. This highlights a major advantage that Lean organizations possess. The Lean infrastructure is designed for continuous improvement, quick response and problem solving up and down the organization. 

An example of this that I heard about on the radio recently, was the changes that college entrance committees were being required to make in their selection process of new freshman students when the last semester of high school was so disrupted and taking SATs (or other admissions tests) has been impossible for health and safety reasons. In some high schools, they went to a Pass/Fail grading system versus the usual four point system. How do these college boards deal with this? How important are college entrance tests; are they really that informative? Many universities have instituted (re-instituted) the entrance essay as a metric for admission. Will these essays become a permanent requirement for admission post Covid-19?

One of the axioms in the Lean environment is to "lower the level of water in the river." When the water level is high, systems and processes seem to sail by smoothly because rocks are covered and we go over them; flow occurs effortlessly. However, this often leads to complacency; a false sense of well being. Lean organizations will routinely introduce small changes to their Value Stream that cause a little bit of chaos. It "lowers the water" just enough to show where the rocks (waste, defects, muda) are. These rocks are problems, never before illuminated, that need to be solved in order to avoid potential, future pitfalls; to survive and to be better tomorrow than we are today. Covid-19 has "lowered the river" exposing dangerous "rocks" among many of our systems, especially healthcare. Lean teaches that systems should be in place that make problems (or potential problems) quickly identifiable and corrected quickly at the root cause level.

For example, if one of your Value Streams (e.g. annual wellness exams) has been functioning very well with five staff members involved, then try changing it to only use four (and reallocate that fifth person to new work that can, perhaps, drive growth for the practice. What problems does removing a person introduce; what rocks pop up? How would your practice deal with that change? How might you have to evolve and improve? 

Or, if your inventory is set at a certain level with a certain reorder point, what changes would be needed to avoid rocks if you decided that these levels be decreased by ten percent, saving capital and carrying costs? But be mindful that lowering the water too quickly can make us crash the boat. You might be able to start by putting 10% of inventory in a separate “emergency use only” location -- and when you can improve your processes to the point of truly not needing it, then use up that 10% without replacing it. 

Or, what would your practice need to change in order to start seeing appointments every twenty minutes rather than every thirty minutes?  How can we do so in a way where nobody feels rushed and so that care and service doesn’t suffer, not to mention the quality of worklife?

By occasionally, but routinely, "lowering the level of the river", Lean organizations start seeing new "rocks" that stimulate innovation, creativity, problem solving techniques, staff engagement and place them even farther ahead of their competition; more capable of sailing in rough times.

It will be very interesting to see what life will be like (better? or worse?) one, two or five years from now because of what Covid-19 has invoked. Though, hopefully, in the future it will not take a worldwide pandemic to teach us the necessity of "lowering the river" and continuous improvement. 

How might this be experimented with in your practice?

Thanks for reading. 

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.

"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.

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.

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.

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.

Customer

For us in veterinary medicine, the external customer is, of course, the client. They are the reason that we are in business, the initiator of a value stream’s work and they are the ultimate determiner of value. But, there are also internal customers. Within a value stream, the customer is the receiver of the product, service, or information from the previous step. For instance, the doctor would be the internal customer of the results in the step that performs a general health profile on a patient.

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.