Just In Time (JIT)

JIT, one of the two pillars of the Toyota Production System, is the procurement and delivery of resources, whether that be drugs, supplies, access to diagnostic equipment, doctors or staff, just exactly where it is needed, when it is needed, and in the amount needed. Nothing more and nothing less. JIT is an ideal direction and goal, but in a real world, we may have “buffer inventories” that protect us from running out of supplies due to variation that we did not anticipate. It is based on the way United States supermarkets restock inventory on the shelves during the night, to replace what was purchased the previous day. For instance, the ultimate JIT would be for a drug company to send you the 14 antibiotic tablets as soon as you dispense them to a patient. Again, in reality, we may choose to order no more than weekly or order in certain box quantities, so we end up with some inventory (this could be viewed as Type 2 or “necessary” waste).

But, as mentioned above, this idea doesn’t have to refer to just inventory. For example, a doctor’s time is limited and his or her skills are unique and valuable. These resources should be committed only in the necessary places, at the correct time and in the right amount. A doctor’s time is best utilized doing work such as diagnosing illness, creating treatment plans, or performing surgery, rather than running fecal exams, drawing blood samples for lab profiles, or invoicing clients. Making sure that doctors are spending most of their time being doctors is another example of the “respect for people” principle or making sure we don’t waste their talents or capabilities. The scenario of the radiographs mentioned above is an example of JIT. They are taken only when necessary and in the amount necessary.

Kanban

The Japanese word for “sign” or “signboard” is kanban. It is a visual means of requesting a resource, e.g. supplies, inventory, maintenance, doctors, etc. In many practices, inventory management is a perpetual problem.  It seems like it is always “feast or famine”; balancing “stock-outs” and expired “over stocks.”  The problem is not the person in charge of inventory. The problem is the system.  And, it isn't just about inventory levels, it is about managing all resources.

One example of a kanban would be an inventory card with the name, location, amount, supplier name, etc. being written on it that would be placed at the reorder point of the particular unit on the shelf to signal reordering. Lean organizations often use “two-bin” kanban systems such as an empty microscope slide box set aside at a specific location (a kanban post) that triggers replenishment of the slides at the microscope in the lab from a central supply area. It could also be a file holder on the exam room door that holds patient records which indicates there is a client and patient in the room ready to be seen, “pulling” the doctor or tech to the room. Or, it could be the plastic, colored flags mounted next to an exam room door that request an action take place in the room such as a doctor is needed, the exam room needs cleaning, or the exam room is ready for a new patient. Kanban is part of visual management, and just-in-time philosophy that we discuss later.

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.

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.”

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.

Gemba

In Japanese, gemba means “the real place.” This is the place where work happens; where the facts can be found. In veterinary medicine, it would be the reception area, the exam room, the surgery room, etc. It is the place to go see where a problem exists, as it exists, when it exists. Contrary to Western management, Toyota understands that if a problem is to be fully understood, then all stakeholders, such as executives, supervisors, managers and workers, must be present at the problem site in order to consider all points of view and ideas, and build a consensus on how to fix it permanently. Lean leaders will “go to the gemba” when there is a problem to investigate and solve. It’s also a common practice to do planned “gemba walks” to get out of the office, to engage with staff, and to see problems and opportunities for improvement first hand.

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.

Value

 

According to Lean, value is defined by three concepts. First, it is something that the client wants or needs and is willing to pay for. If the client brings in a pet, but is not willing to pay for vaccinations, they are obviously not valuable to the client, at least at this time, and we certainly would not perform that service. Secondly, it must move the care process forward in some, in terms of comfort, diagnosis, treatment, or education -- working toward restoring or maintaining health and wellness. The pet presented for vaccinations must be moved towards a more healthy condition by actually vaccinating the animal. And, thirdly, it must be performed correctly the first time (quality). Giving the wrong vaccines or inappropriate vaccines is of no value. Especially, if we have to go back a second time and vaccinate with the appropriate vaccines.

If a step is not value, it is waste. Lean organizations are focused, ultimately, on adding value from the client's point of view.  Improved efficiency, improved safety, reduced costs, better resource utilization, increased staff engagement, a culture of continuous improvement, and quality are all important aspects of Lean, but they are by-products of the methodologies Lean uses in order to provide value to the customer from the customer's point of view.

It’s important to note that adding value and being busy are not the same thing. Just because you are running around doing something, does not mean you are adding value. There is a lot of motion and activity involved in chaos, but the vast majority of it is not adding value to the patient or client.

Some Basic Concepts

 

As consumers, we all have had those epic experiences with call centers, auto repair shops, plumbers, etc. Why can they not see the consumer’s point of view? Yet, back in our practices, our “provider hats” go on, and we, too, fail to consider what our clients have to deal with. In Lean, the perspective of the consumer is the priority.

One of the goals of Lean is perfection. The book Lean Thinking talks about the “continuous pursuit of perfection” (and that also might remind you of a Lexus ad slogan). We know we will most likely never get to that point of absolute perfection, but we continually try, working toward an ideal state of safety, quality, waiting times, customer satisfaction, and other meaningful measures. Just as repeatedly dividing one in half will never get us to zero, it does get us darn close. If we can eliminate 50% of waste with each attempt, then after only 5 iterations, we have removed 96.875%. That’s not perfect, but really, really close (and more importantly, far better than our starting point). With just two more iterations, we get to 99.21875%. That's really, really, really close! The Lean mindset of continuous improvement drives us to solve problems that matter and to keep working at it. Think of how to do it, not why it cannot be done.

Try to keep an open mind. Lean is not particularly difficult to understand in concept, but it is different… and it can be difficult to change an organization of any size. Discard conventional thinking. It has proven itself over and over in every company and industry that has embraced it as a complete package and given it an honest trial, practicing Lean over time. We believe the same will occur in the veterinary medicine setting.

Nothing is written in stone. Lean is about experimenting in order to deeply understand and improve. But, if that doesn't happen, we can learn from it, adjust and try again. "Best medicine does not equal absolutely correct. In school, they told us that 80% of what we were learning would be proven wrong. We just didn't know which 80%. It's the same way with best management practices. Keep iterating.

Lean takes a systems approach to management. It tends to blame faulty systems rather than people. Systems are the responsibility of management, not the workers. Workers are at the mercy of systems, and systems can be very complicated with strange ramifications.

Lean is, foremost, concerned about quality. Toyota has been able to turn operational excellence into a successful business strategy. Facebook, Twitter and practice web sites have accelerated and amplified the effects of “word of mouth” advertising.  Before you promote, you better have “all of your ducks in a row” or all of your time and money may actually be counter-productive. Remember, prepare to promote and then promote!

Lean originated out of manufacturing; automobile manufacturing more specifically. And, although it has been successfully implemented in almost every industry, including human health care, it will require some adapting for use in veterinary medicine. This technology has only been experimented with very recently and only on a very small scale in veterinary medicine. This will be a new paradigm for us. We are the ones who will define Lean in our industry.

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.