"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.

"Pushy" Rescue Groups

I thought I would look, again, at “push” vs. “pull” systems. Though I have written on this topic before, it can be a little difficult to comprehend. What we are really looking at is when the customer enters the value stream.

If the customer comes onto the scene at the end of the value stream, then we are probably looking at a “push” type system. The product is manufactured and sent to market where, hopefully, there is a customer (or millions!) eagerly waiting for the store doors to open in order that they can purchase said product. We don’t identify a particular customer until the end of the process cycle.This system is typically chock full of wasted inventories along with the warehousing costs to store all of it, not to mention the capital tied up until the first sale is made.

On the other hand, if the customer enters the value stream at the beginning, then we are most likely observing a “pull” system. It is a particular customer order that triggers (begins) the manufacturing of that product, at that time, for that customer. This means relatively little inventory, with little to no warehousing and associated costs.

Let’s take, for example, your basic, “walkin’ down the street” rescue group. They go to the local animal control facility where they pick those animals they think (or hope) can be adopted out later. At some point in the future, they take the animal to a veterinarian to be examined, vaccinated, checked for intestinal parasites, tested for heartworms or FeLV/FIV. If the animal is ill or needs other medical attention, then additional visits may be required. At a later time, the intact animals are returned to the vet for spaying or neutering. The veterinarian is, of course, paid for his/her time, drugs, supplies and knowledge; all of this is an investment on the part of the rescue group. In between all of these steps and at the end, the rescue has to “warehouse” all of these pets in foster homes until a suitable adoptive family can be located, if at all, and recoup their costs by charging an adoption fee. This is a “push”system. The customer (adopting family) only becomes known at the end of this value stream.

If the rescue group utilized a “pull” system, the value stream would begin with the adopting family requesting a certain pet; i.e. a certain species, breed, gender, color, age, etc. and then, only then, the rescue group would scour the local “pounds” until a match was found. The pet would go to the vet for any routine procedures or medical care. It would then be given to its new family for an appropriate adoption fee. No warehousing. Any money spent is basically paid for by the adopting family immediately or, at least, much quicker than in the “push” scenario.

In general veterinary practice is a “pull” system, but there are places where we “push”, also. In my next blog, we will revisit the concept of “internal customers” and “pushy” veterinary processes.

Thanks for stopping by. As always, your comments and questions are welcomed.

Vince, why pursue perfection?

Thanks for checking in.

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.

Have You Checked Your SMED, Lately!

SMED stands for Single Minute Exchange of Dies. One of Shigeo Shingo’s and Toyota’s greatest gains in increasing flow was figuring out how to change the extremely large, heavy dies used to produce (stamp) the large body parts of different car models quickly. Toyota was able to improve this changeover time for one part to another from an industry standard of many hours (often eight or more) to less than five minutes!

So, what did this allow Toyota to do? It allowed them the ability to make smaller, more efficient, lots of the different models of cars. When you lose a whole day of production to change the dies, you can’t afford to do it very often. Which means, for economy's sake, you need to make large batches (there’s that “b-word”) at one time, which, also, means large inventories of parts, which then need to be paid for and stored at high costs. All very “un-Lean.” Toyota was a small company back then. They couldn’t afford any of that and stay competitive. Plus they had a small market in Japan and had to challenge themselves to produce a high mix of different products.

What did Toyota do? They had a need, a problem, that required a solution. Shingo and the workers got to work using what we’d recognize today as A3 Thinking. They went to the gemba, observed every aspect of the change over, “brainstormed”  possible countermeasures (together), and experimented until they reached their goal, or very close to it, being much better than before.

The equivalent of SMED in veterinary medicine is the time it takes to get an exam room ready for the next patient, or the surgery room ready for the next procedure, after you’re done with the previous. How fast can you go from spay to neuter to dental to cat abscess?

In essence, what we are are doing is looking at the flow between “flows”; identifying the time (delays and activity) between value added operations. A competitive swimmer must perfect his/her strokes and pace, but races can be lost by sloppy "flips" between the laps. So, swimmers must perfect this process, also. How fast can you “reload, aim and get ready to fire, again?” Consider ways to eliminate waste, 5S projects in the exam room or surgery room to facilitate quick change over, standardizes work to get everyone on the same page, and improved resource (doctors, staff, supplies, inventory, etc.) utilization through kanbans (signals).

What does this mean for a vet clinic? For example, could the previous surgery be recovered someplace other than the surgery table? Could a staff member clean and repack instruments while the doctor is busy performing the next procedure so they are ready to be autoclaved later? Could a trained, licensed tech induce anesthesia, intubate and prep the next patient while the doctor is placing skin sutures in the current patient? If so, what safety procedures and standardized work would need to be put in place? In the past, I have allowed trained staff to draw up injectable anesthesia, inject it, intubate the patient and start prepping. BUT, a second trained tech had to verify the proper type and amount of injectable anesthesia, and had to double-check the correct endotracheal tube placement. Any uncertainty or questions resulted in a halt of the process by those involved until verification and resolution by a doctor could occur.

In all of my years of practice ownership and management, I had never thought about, or even heard about, this concept before. That is one of the things that intrigues me so much about Lean. The different perspective and mindset that it brings to the day-to-day practice of veterinary medicine.

So, after some work on improving your value streams, take a look at your own SMEDs. Don’t be embarrassed!  And then, let us know how it went!

An Interview with Samantha Parrett: NC State Vet Hospital's Dive Into Lean

I am especially pleased to present this edition of leanvets.com for a couple of reasons.

1)  It is the first podcast for me. Hopefully, others will follow in the future as subject material arises. I debated whether to present this blog as a written interview or as a phone interview. Mark Graban, my “partner in crime” for this thing, convinced me to try a podcast and said he would set it up, which he did. Thank you (again), Mark. (This is also being "simul-blogged" on Mark’s wonderful site, LeanBlog.org). I am so glad we did it this way. I want everyone to appreciate the enthusiasm and confidence about this Lean veterinary success that Samantha brought to the interview, which wouldn’t have been so apparent had we done this in a written, email format.

2) This references, to my knowledge, the first published report of the Lean philosophy and methodologies being applied in the veterinary practice arena. AND… it was very successful.  It has been very difficult trying to educate my profession on the merits of Lean. We’re a stubborn lot, at times. “It may work for building cars and even for human hospitals, but this is veterinary medicine. We’re different! Show me the proof it will work in our profession.”, everyone would say. Well, here’s at least one report that indicates veterinary medicine can benefit from Lean, the same as everyone else who has made the commitment to give it an honest trial.

Our guest today is Samantha Parrett. She is the Director of  Business & Administrative Services for North Carolina State Veterinary Hospital. I first came across NC State’s story, “NC State Vet College Dives Into Lean,” last summer while Mark and I were preparing our lecture for the 2016 TVMA Convention and Expo. I have been waiting eagerly for the opportunity to learn more ever since.

There are several points I would like to draw your attention to. 

First, is the enthusiasm and conviction that comes from trying Lean and experiencing the success that can be realized from Lean. 

Second, Sam mentions many of the Lean concepts and “tools” that we have tried to explain here at LeanVets.com. This demonstrates the “real world” applications of these methods. 

Thirdly, the problem of getting more of the surgeries performed during the normal business hours which had been unsuccessfully remedied for a number of years, finally found some success through Lean. 

And lastly, the positive effect the Lean mindset has had on the staff, doctors and, even, students at NC State Veterinary Hospitals. Lean works...even in veterinary medicine!

Thank you for listening. Here is Ms. Samantha Parrett’s interview.



To read a transcript of the interview,  click here.

The 3rd edition of Mark Graban's Lean Hospitals is now available

You all can breathe again! Mark Graban's Lean Hospitals, 3rd Edition is now available. The fact that there is a 3rd edition speaks volumes about the quality information found in this book and the respect it has garnered within the field of Lean Health care. 

My copy of the 1st Ed. of Lean Hospitals by Mark Graban

The picture to the left shows my copy of the first edition of Lean Hospitals.

As you can tell, it has been well read and shared with many interested staff and colleagues. I also have the 2nd edition, but it is a Kindle ebook and, therefore, impossible for me to show how much I have referenced it, also. 






My copy of the 3rd edition has been ordered. I'm going back to the actual book format (although it is also available from Kindle). I like being able to "dog ear" page corners, write notes in the margins and stick different colored Post-em notes to the pages to remind me of the great ideas and insights I get every time I read Lean Hospitals.

If you only get one book to read about Lean in general, and Lean Healthcare specifically, Mark Graban's Lean Hospital, 3rd Ed. is, by far, the book to get. Order your copy here!

Seeking General Questions: A Forum MVP

No, not "Most Valuable Player." MVP in this case stands for "Minimal Viable Product. It comes from the book The Lean Startup by Eric Ries. It is his entrepreneurial form of Lean.

The idea is to get the bare essence of your idea or product out to the public and then started iterating as rapidly as possible based on feedback from your customers. Get feedback, make changes, redeploy,  get feedback, etc. The faster you are able to do this, then the faster you learn what is valuable to your customer or not, and the farther ahead of any potential competitors you will be. Whoever gets to market with a viable product has the best chance at capturing market share. Of course, maintaining that lead is a different story, and this is where all of the rest of the Lean concepts come into play. This blog is my MVP into Lean and veterinary medicine on the Internet.

So, I am going to run a small experiment. I originally had a page of this blog devoted to a forum, but decided learning about and maintaining  both a blog and a forum was redundant and too much at once. So, I dropped the forum page.

It occurred to me, however, that, maybe, some of you might have other questions about Lean that don't necessarily fall neatly under one of the already posted articles. Therefore, this  post is my MVP for a forum, possibly, sometime in the future. If you have any  questions or comments about Lean, Lean in veterinary medicine or this blog, please send a comment to this post below. I and/or Mark Graban will respond ASAP.  If I get an indication that a forum would be of value, I will reconsider adding it to  the site.

Please use the  comment section below to ask any questions or leave any comments. Thanks for checking in!

What Is This Takt Time You Speak About?

When I first started learning about Lean, one of the terms I seemed to have difficulty wrapping my brain around was "takt time."

Or, maybe it was getting straight the difference between takt time, cycle time, lead time, process time, value creating time, non-value creating time and all of the other “times.”

At any rate, if you read much about Lean, you will come across the term. So, I thought I would explain.

According to Lean Lexicon-5th Ed by the Lean Enterprise Institute:

Takt Time is the available production time divided by customer demand. For example, if a widget factory operates 480 minutes per day and customers demand 240 widgets per day, takt time is two minutes. Similarly, if customers want two new products per month, takt time is two weeks. The purpose of takt time is to precisely match production with demand. It provides the heartbeat of a lean production system. Takt time first was used as a production management tool in the German aircraft industry in the 1930s. (Takt is German for a precise interval of time such as a musical meter.) It was the interval at which aircraft were moved ahead to the next production station. The concept was widely utilized within Toyota in the 1950s and was in widespread use throughout the Toyota supply base by the late 1960s. Toyota typically reviews the takt time for a process every month, with a tweaking review every 10 days.

And:

Cycle Time is the time required to produce a part or complete a process, as timed by actual measurement.

For example, if you have 90 clients wanting routine annual exams and vaccinations performed on their pets each week and you have 30 planned hours available Monday through Saturday (40 hours/week/doctor, less surgery time, less in-patient treatment time, less new sick pet time), then your takt time is 30 hours/90 visits or or 1800 minutes/90 visits or 20 minutes per appointment.

Takt time is a time that represents the pace at which you need to work in order to meet current demand. To meet demand within the allotted time, a routine annual exam would need to be completed, on average, every 20 minutes.

In order to find the cycle time, an actual measured time, you would measure several appointments and calculate the the average time required to actually complete them. If you have a lot of variation, you might measure ten appointments, which is a good Industrial Engineering guideline (thanks to Mark Graban for that tip).

If the actual cycle time is less than or equal to takt time (meaning you can work faster than the demand rate), then you can meet demand within the available time restraints and everything should be good.

But, if cycle time is greater than takt time, then you definitely have a problem, because you cann not meet demand as performed within the time requirements. This scenario will necessitate a kaizen project and/or A3 thinking to work out some countermeasures. These might include finding more time for these exams sometime during the week (expanding your working hours), or eliminating waste and improving flow so the cycle time falls within takt time. We'd want to reduce the time it takes to complete the appointment, but without rushing or impacting quality or client satisfaction.

In manufacturing, it is sometimes a little less complicated because product is often moving through the production line at a much more precise interval and the time for each step has very little or no variation. So, cycle times in manufacturing are much more consistent. Manufacturers also have the opportunity to level their production rate by using inventory as a buffer against variation in demand. In a vet clinic, we might be able to somewhat level our workload through appointment schedule, but if we're taking walk ins, we have to be able to react and adjust to that variation in demand.

But, again in veterinary medicine, we have more variation. There is variability in how long an annual exam actually requires. Are there issues that need to be addressed? Will a fecal exam be required? How about a heartworm test? How many vaccinations are due? Do medicines needed to be filled and dispensed? In addition, there is variability in the arrival times of clients, even with appointments. This results in variance squared (variance X variance), and that = chaos.

There are two points that should be made here. The first is that variability is a form of waste and should be reduced as much as possible using the Lean mindset and methodologies. Meeting takt time is a first goal. The second point is that this is the reason you probably should not schedule more than 85% of your available appointment times. This allows you some "wiggle"room. I have heard some advocate high density scheduling, i.e. close to or at 100% booked.  But, even with a highly trained staff in a Lean environment, you just can't escape variation. The first time an appointment goes long or a client shows up late, you are behind schedule which means each subsequent appointment will have to wait. Waiting is muda. High density appointments are not value for the client, from the client's point of view.

In a later blog, I hope to write about queueing theory, exponential statistical distribution, and Poisson distributions. These concepts produce more realistic models that take into account the variabilities of arrivals and cycle times.

Resourses for Lean Veterinary Medicine

Here are some recommendations for further reading and web resources. At some point in the future, this post will be moved to a separate page of this blog to facilitate future additions and updates.

Enjoy! And, be sure to let us know what you think or if you have a recommendation for an addition to the list. 

Suggested Reading:

Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, 2nd. Ed. by Mark Graban

Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvement by Mark Graban and Joseph E. Swartz

Follow the Learner: The Role of a Leader in Creating a Lean Culture by Sami Bahri, DDS

Management on the Mend, by Dr. John Toussaint

The High Velocity Edge, by Steven J. Spear

Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience by Charles Kenney

The Toyota Way: 14 Management Principles From the World’s Greatest Manufacturer by Jeffrey K. Liker

Lean Thinking: Banish Waste and Create Wealth in Your Corporation by Daniel P. Womack and Daniel T. Jones

Lean Lexicon: A Graphical Glossary For Lean Thinkers; 5th Ed. by the Lean Enterprise Institute

Value Stream Mapping for Healthcare Made Easy by Cindy Jimmerson

Toyota Production System: Beyond Large-Scale Production by Taiichi Ohno

Workplace Management by Taiichi Ohno

Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor, and Lead by John Shook

A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste by Cindy Jimmerson

Out of Crisis by W. Edwards Deming

Harvard Business Review article, "Time-and-Motion Regained" 

Web Resources:

Lean Enterprise Institute              

ThedaCare Center for Healthcare Value

Mark Graban’s Lean Blog              

Kaizen Institute                 

Shingo Institute                  

Toyota TSSC                    

Toyota’s TPS page