Prepare To Promote, THEN Promote

It seems to me that, on balance, there is an inordinate amount of attention and money spent on advertising, optimizing social media presence and attracting new clients without much thought being given to our practice systems and foundations. Of course, marketing is necessary and important, especially in this day and age. But beware of "putting the cart before the horse."

Make sure you are as close as you can be to your True North; that you have done everything you can to reduce wastes, improve quality and flow, utilize resources effectively and maximize value to your clients from their perspective before you embark on PR projects. Marketing poor systems and value streams is not the kind of PR you want.

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R-E-S-P-E-C-T

“Respect for people” is a fundamental principle of Lean and a major difference between Lean and the Western, more Taylor-esque, concept of management. The Western tradition, which is still a part of educating MBAs, is that management knows best and makes all decisions. Workers are to do as they are told.

There is a quotation by Henry Ford to the effect that the problem with workers is that, not only do they come with two hands, but also, unfortunately, a brain. Workers are not hired to think! Lean is much less of a top-down style of management, and much more of a bottom-up, inclusive, transparent style. This is not to say, however, that the asylum is completely handed over to the patients.

This core belief influences the relationship Toyota managers and supervisors have with their workers. For Toyota, management’s primary function is more of teacher and less of an organizational police officer. We now understand, more than before, that the focus for Toyota is not just on building quality automobiles, it is primarily focused on the building of problem solving, innovative, respected employees who, then, build quality, innovative automobiles.

Dealing with people from a basis of respect permeates every aspect of Lean.

Systems thinking:

Have you ever had the feeling that, at some point at work, you were damned if you do and damned if you don't? Or, that you are in the the middle of a Catch-22 situation? If so, you have probably been the victim of poor systems or systems colliding with each other. That feeling of not being in control or at the mercy of things bigger than you.

Thinking in terms of systems means understanding that the systems at work within an organization are management and leadership designed. Systems are the responsibility of management. Workers have no authority to control or overhaul systems. They are at the mercy of the systems. Yet, many times, staff are blamed for what is, in actuality, a system design problem.

For example, if a job is not being performed well, systems thinking would first consider such things as does the worker know that job is their responsibility, has the worker been trained adequately, does the worker have the necessary tools, and does the worker have timely and correct information?

Systems thinking is more respectful. It recognizes that systems should be investigated when problems occur before blaming people.

Value:

The Lean definition of value is that which the client wants and is willing to pay for, and that improves the health status of the pet, without defects and waste along the way. Our clients get exactly what they want, when want it and in the amount wanted. They pay for only value adding services. The concept of defining value from the client’s point of view shows respect for them.

Variance and overburdening:

Lean understands that large variances in workload can be the source of difficulties and overburden our staff. Lean suggests work loads try to be leveled as much as possible. Being watchful for the overburdening of staff comes from respect.

Just-In-Time

The Just-In-Time (JIT) concept is the procurement and delivery of resources, (whether that be drugs, supplies, access to diagnostic equipment and information, or patients, doctors and staff) just exactly where it is needed, just exactly when it is needed, and just exactly in the amount needed. Nothing more and nothing less.

With respect to staff and personnel, the Just-In-Time idea is based, in part, on recognizing and respecting the unique value of everyone's time and skills; to only use them when, where and in the amount needed.

Standardized work

Standardized work is the mutually agreed upon method to do or handle a certain process or situation that helps insure quality, timeliness and safety, and gets everyone on the same page working in the same direction. It shows respect by involving staff in its definition and formal writing, and by eliminating ambiguity and the anxiety it causes to workers that come from policy and process chaos.

Kaizen

Kaizen is a Japanese word that can be translated to mean “good change,” “change for the better,” or “continuous improvement.”

While improvements can be large, time consuming and expensive major changes, the most common are the small, daily, quick, inexpensive ideas submitted by staff that improve quality, flow, safety, value to the client and make work life just a little easier. Staff are on the frontline of our practices every minute of every day. They know, better than anyone, where and what the problems are. And, they probably know better how to remedy them than we owners and managers do.

Kaizen shows respect by recognizing what an asset our staff is, and allowing them to partner with us in improving the practice; to be engaged and be part of the solutions, rather than always being blamed for the problems.

5S

5S projects are the physical cleaning and reorganization of a particular room or area of the practice. It helps the staff to work with less clutter, frustration and confusion on a daily basis. It creates better flow within the hospital which increase value to clients; all ways of showing respect.

Go to gemba

"Genchi Genbutsu" (go and see) means that whenever there is a problem found, all relevant stakeholders (management and staff) should go to where the problem occurs (the “gemba”) and solve it together. It shows respect by recognizing that staff have valuable input to the situation.  

The Andon cord

On the Toyota production line, workers are provided with a mechanism to sound an alarm and ask for help anytime they find it necessary. The line stops if the problem is not quickly resolved. Toyota trains and trusts its employees to use the Andon cord when an issue of quality or safety is in question. It shows respect by creating a culture of safety and trust for anyone to speak up, even if they think there might possibly be an inkling of a concern.

It is my humble opinion that if veterinary staffs knew about and understood the Lean mindset and its worker-centric (and client-centric) philosophy, there would be such a grassroots revolution within the profession that owners, managers and corporation leadership would have no choice but to start thinking Lean within their practices. Maybe, we could start now and circumvent all of the "bloodshed."

Thanks for stopping by. Please share this blog with your contacts! And, let me know if you have any questions, comments or post ideas.

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.

                                       *****************************************




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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Error Proofing vs Fool Proofing

This blog post is about a Lean concept that I have wanted to share with you for awhile. It concerns the idea of error proofing or mistake proofing (poka-yoke). 

There is another similar term, baka-yoke, which translates as "fool proofing." 

Toyota prefers the former term because it is less derogatory and more respectful of the worker. It shows a systems mindset. It reflects Lean’s focus on “how” and “why” an error or defect occurred rather than “who is to blame.”

When I first graduated vet school in 1980, I purchased a personal computer (anyone remember Radio Shack’s TRS-80?) and started to learn programming. I was interested in writing small programs that would make my work easier. Eventually, I wrote a management program for my practice.

As part of the programming, it was necessary to identify proper data input by the user, so that the software would run as designed and not “crash.” If input errors were found, the user would be notified of the problem and asked to re-enter in the proper format.

For example, if the user was asked to enter a telephone number using the format (###) ###-####, I would have to write a section of code to check for proper input.

1. Are all the characters entered either a number, a “(“, a “)” or a “-“?
2. Were a total of 14 characters entered, including parentheses, spaces and dashes?
3. Was the first character entered a “(“?
4. Was the fifth character entered a “)”?
5. Was the sixth character entered a space?
6. Was the tenth character entered a “-“?

A similar set of programming code was required each and every time input was requested from the user-- very time consuming and added tremendously to the length of the program. But, GIGO (Garbage In, Garbage Out), and nobody wants that!

We can see this same idea in use all around us-- from simple warning signs to designs that make errors difficult or impossible. A three-pronged plug can only be plugged into a wall socket one way.

In general, there are five levels of error proofing, as explained by Mark Graban when he teaches Lean.

                                                                            Graphic courtesy of Mark Graban

As the graphic indicates, simply posting a sign admonishing workers to “Be careful” is the least effective. Making it impossible to make an error in the first place is the most effective means.

In the above pictures, the hospital gas panel has two ways of error proofing. First, the different hookups are color coded as a visual measure to indicate which gas hose goes to which port. Secondly, the pins of the hookup will only connect and lock with the appropriate gas port. 

Idexx has error proofed their VetTest blood test slides by designing them with strategically placed notches on the edges. With this design, the slides can only be placed in the analyzer in the proper orientation.

The file folder color coded end tabs do not prevent misfiled folders, but it illustrates the error proofing concept of making the error easier to detect.

This is an illustration of just how ineffective warning signs are. If management really wanted to control the light in the closet, maybe a motion sensing light fixture would be a better option. The light would come on when someone walked in, but would then automatically turn off shortly after the individual left. 

This next photo is something that a client of Mark Graban's shared with him years ago. Mark's not sure of the origins, but the tracks in the snow show how easy it was for somebody to just drive around the gate in the road. This wasn't error proofed (and maybe the gate was broken or not needed anyway).

Photo courtesy of Mark Graban

Of course, sometimes…where there is a will, there is a way! What are you going to do?!?

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Heads up! I will be the guest presenter on a webinar series hosted by Mark Graban and KaiNexus on May 7th at 12:00 noon Central time. We will be discussing the new emergence of Lean management in veterinary medicine.  Use this link. Hope you will join us!

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!

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.

Waste (Muda)

In Japanese, the word for waste is muda. Any time, activity or resources that do not add value can be considered waste. Traditionally, there are seven forms of muda. However, many Lean practitioners have added an eighth, in recent years.  The “waste of talent” or the “waste of underutilized human potential” is the waste of not utilizing staff effectively, not acknowledging their unique talents and perceptions, or potential intellectual contributions. Lean considers people to be the most valuable asset in an organization. Lean encourages us to seek the wisdom of ten people, rather than the knowledge of one.

As stated in the book Lean Hospitals, the types of waste and their definitions are:

Defects
Time spent doing something incorrectly, inspecting for errors, or fixing errors.
Ex.: Surgery pack missing the scalpel handle; replacing a bandage that was applied too tightly.

Overproduction
Doing more than what is needed by the customer or doing it sooner than needed.
Ex.: Labeling heartworm preventative before the test results are available.

Transportation
Unnecessary movement of the “product” (patients, specimens, materials) in a system.
Ex.: Repeatedly taking a patient back and forth to a cage because resources are not available when needed.

Waiting
Waiting for the next event to occur or next work activity.
Ex.: Waiting for the processor to be turned on and warmed up before being able to take a needed radiograph.

Inventory
Excess inventory cost through financial costs, storage and movement costs, spoilage, wastage.
Ex.: Ordering 3 years worth of ointment because you got a free pair of “earbuds” for your smart phone.

Motion
Unnecessary movement by employees in the system.
Ex.: Chasing down the pair of bandage scissors that belong in Exam 1.

Overprocessing
Doing work that is not valued by the customer or caused by definitions of quality that are not aligned with patient needs.
Ex.: Centrifuging a blood tube longer than necessary; collecting client email addresses that are never used.

Human potential
Waste and loss due to not engaging employees, listening to their ideas, or supporting their careers.
Ex.: Idea by staff to attach a small basket to front of cage to keep patient personal items and meds from being misplaced is ignored.

There are two types of muda. Type 1 muda is “necessary waste,” or at least necessary for the time being. For example, taking time to write medical records is not something that the client would voluntarily pay for and it does not physically make the patient any healthier (transform the product), but it is necessary in a veterinary practice for legal or other reasons.

Type 2 muda is unnecessary waste. It is waste that can be removed immediately without causing any other ill effect. For example, waiting an excessively long time for the doctor to get into the exam room. This is not something that the client would pay for and it does not make the patient healthier. It has no place in the value stream. This category is sometimes called “pure waste.”

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.

A New Paradigm For Veterinary Practice Management

 

There is a new paradigm, a new methodology, with proven results over many different industries including human health care. The new model is the Toyota Production System (TPS), better known in the West as Lean, for its consistent ability to deliver both quality and value without the waste and frustration that we see in so many organizations.

Over the course of 70 years, Toyota has grown from being a small, domestic, truck manufacturer in a devastated post-war Japan to being the largest auto maker in the world, for a time in 2012, even surpassing America’s industrial revolution icon, Ford Motor Company. Additionally, they have been profitable in every one of those years except three. How has Toyota been able to accomplish such milestones? By relentlessly pursuing a strategy of operational excellence, which includes a leadership style and organizational culture that is very different than most companies.

Lean is not just a set of tools. Toyota’s own website describes their production system as being a combination of:

1. Technical tools and methods
2.  Management methods
3. Philosophy and mindsets 

Practiced together, this results in an organizational culture that develops people in the organization and sets up the organization for long-term success. Toyota also emphasizes that the main goals are improving flow (in the case of healthcare, providing the right care at the right place at the right time) and ensuring quality at the source. There is a foundation of safety being a top priority (for patients and employees) instead of being a separate program or initiative. 

            Toyota also described their “Toyota Way” management system as having two key pillars:

• Kaizen (continuous improvement) (http://www.leanvets.com/2016/02/kaizen.html)
• Respect for People 

Being respectful in the workplace is not just a matter of being nice. It means challenging people in a constructive way so they can grow and perform to the best of their ability. “Respect for people” is a phrase that is also sometimes expressed as “respect for humanity.” This means not just showing respect for all stakeholders (such as customers, employees, suppliers and the partners, the community), but also respecting our human nature. For example, Lean leaders understand that we have human limitations, such as making more errors when we get distracted or are physically or mentally exhausted. This drives us to error proof systems to help prevent common human errors, rather than just asking people to be careful.

In the Lean framework, operational excellence is based concepts, such as the following:

1. Value (http://www.leanvets.com/2016/02/value.html) is defined from the customer’s point of view.
2. Work relentlessly to reduce or eliminate waste (http://www.leanvets.com/2016/01/in-japanese-word-for-waste-is-muda.html).
3. Build a culture of continuous improvement.
4. Standardize work to improve flow.
5. Make problems visible and react quickly.
6. Understand problems and solve them at their root cause(s).
7. Demonstrate deep respect for workers and all stakeholders. 

Successful practices realize that long-term success comes from satisfied clients. Clients should truly feel we have their best interests at heart. Hopefully, they would choose our practice not necessarily because we are less expensive than another practice, but that they received value for the hard-earned money they spend with us. We are responsive to their desires, and we value their time as much as we value ours. Satisfied clients help resurrect the idea of positive, direct ”word of mouth" advertising.