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.

5S

5S is part of the Lean approach to of “visual management,” as a way to show problems and irregularities, so they can be fixed quickly. As such, it is also an aspect of flow, standardized work and the elimination of waste. 5S deals with workplace organization, i.e. exam rooms, pharmacy, lab, surgery, or even the organization of email and information, etc. The workplace is organized to make work easier, clutter is removed, areas are cleaned, and the locations for supplies and movable equipment are labeled. A place for everything and everything in its place (once we figure out the right place!), and in the right amount. It requires the answering of two questions: (1) Do we have all that we need at the gemba, and (2) Do we need all that we have at the Gemba?

The five Ss stand for:

Sort (Seiri)
Go through the work area looking for any old, expired, irrelevant or broken items, and remove them. Throw them away or, at least, get them out of the way (if they are items that are used infrequently or non urgently). Do you really need to keep rabies certificates from 1987? Does anyone even know what a hemocytometer is, let alone still use it? Besides, the latex tubes disintegrated a decade ago!

Straighten (Seiton)
For everything else that remains, organize it. In the exam rooms, for instance, you try to make each exam room similar to the others so that there is continuity from one exam room to the other. Items used more frequently should be placed closer at hand to save time for staff and veterinarians, which can reduce delays for patients and increase office capacity and throughput.

Shine (Seiso)
Clean up the area and have a process for ongoing cleaning and sanitizing (as a form of standardized work). This minimizes contamination and infectious disease. The regular shine process is also the time to check equipment and perform timely maintenance. This keeps the hospital in a state that is a source of pride, with improved quality and safety

Systemize (Seiketsu)
Once the first 3Ss are done, we need to help make this an ongoing system, rather than a onetime activity. Ask if each of the drawers in cabinets, in each of the exam rooms, contain the same supplies and are they arranged in the same way? Systematizing helps prevent confusion and wasted time looking for items. This step provides the method to the madness. Label the drawers, cabinets and even the tops, so everyone knows what is supposed to be there and can easily see if it is not. It is similar to the woodworker who paints silhouettes of his hand tools on the wall to show where they belong, and to quickly, visually highlight when they might be missing.

Sustain (Shitsuke)
Again, 5S is not meant to be a one-time project. It should be an ongoing activity in the practice, to keep things organized, and to be continually improved. Management oversight, 5S audits, and continued improvement are the key to ongoing 5S success.

Standardized Work

Mary is licensed veterinary technician. When a shocky, weak puppy was presented, Dr. A tells her that a PCV and blood glucose is always indicated in cases such as this and should be performed even before the doctor sees the pet. Two weeks later, a similar case presents and Mary performs both tests immediately upon intake. Dr. B, the doctor on duty, pulls her aside and angrily instructs her to never perform any blood tests without orders from the case doctor.

Unfortunately, we have all been witness to such scenarios. The doctors may not realize these type of situations are occurring.  But, the effects on staff can be far reaching.  It engenders feelings on the part of staff of anger, resentment, confusion and loss of confidence in management.

In the Lean method, “standardized work” is our definition of the best way to do work in a way that ensures safety and quality, while driving the best productivity and minimizing delays for the customer. It is the foundation for continuous improvement and employee empowerment. It is necessary for “flow” and “pull”. Standardized work gets everybody on the same page and reduces employee anxiety. When processes are in chaos, they must first be brought into some semblance of stability. What is the best way to do our work? This stability (and ongoing improvement) is achieved through standardized work. Once there has been some degree of order established, then the processes can be improved by applying other Lean methodologies, such as kaizen.

Standardized work is not the same as “standard” work. Standard work might imply written in stone, inflexible, inappropriately detailed or micromanaged. Standardized work is broader in concept. Think in terms of simple algorithms or checklists. For example, requiring the drawing of a blood sample for a routine health profile into a 3 cc syringe as opposed to a 5cc syringe would, in most cases, be too detailed for standardized work. However, in the diagnosing of the cause of a “red eye,” it is important to specify that the Schirmer tear test be run prior to staining the cornea or using any topical anesthetic drops in order to check for glaucoma. “Canned” computer estimates might be thought of as another form of standardized work in that they do not dictate a specific recipe, but suggest considering the need for such drugs or services such as antibiotics, hospitalization, analgesics, diagnostic tests, etc. They act as a reminder.

When we create standardized work documents, it’s important to ask what should be standardized and to what level of detail. What problems are solved or prevented by having standardized work? What goals are being accomplished? The goal is not to have standardized work. The goal is better performance in all dimensions and a better workplace for all. Standardized work is a “means to an end”, not a raison d’etre. As mentioned above, the reason for standardized work is to start the process of improvement, which ultimately is for the purpose of increasing quality and value for the client, the “holy grail” of Lean.

Chaos must be brought under some control with Standardized Work before Lean "tools" can improve processes. Note that the blue dot becomes increasingly evident as abnormal as the process is first standardized and then improved. Lean helps identify problems.

But there are also some important ramifications. Like most of the methodologies that make up TPS, standardized work is designed by consensus with staff.  Consensus means obtaining ideas for problem solving from all stakeholders, including staff. It comes from the mindset that all workers have valuable input, knowledge and skills that are assets to the organization in problem solving. It is a sign of respect for workers. It does not mean that all opinions are valid and must be taken or that each individual gets to do the work however they want. Toyota has long emphasized that standardized work must be created by those who do the work. It is not dictated by managers or experts.

By involving workers in this way, a vital resource is utilized and leads to increased “buy in” and engagement. It improves communication and reduces anxiety on the part of everyone of not knowing what is the correct (preferred, agreed upon) way or doing something incorrectly. It helps insure that vital information is available even if a key staff member is absent or has moved on. Plus, standardized work becomes the basis for a formal, in-house training program and is the foundation for continuous improvement.

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.