A Different Kind Of Rounds: Lean Daily Management

As doctors and veterinary staff, we are well acquainted with the daily ritual of morning or change of shift medical rounds. This is the gathering of hospital staff and doctors to be updated on the current status of all of the patients in the hospital for treatment, and for the dissemination of new treatment orders by the doctors in charge. This is a form of standardized work. It gets everyone on the same page in a routine and timely manner.

Lean Daily Management (LDM) serves the same purpose, but for the operations and management side of the practice.



Each morning, leadership and management go to the gemba to meet with staff of a particular area of the practice to go over that area's board. What numbers are up (and why?) and what numbers are down (and why?). Or, better yet, do the Process Behavior Charts (PBC) of the data show any "signals" or is it all just "noise?" (see also Mark Graban's book "Measures of Success") What countermeasures should be tried? Any new kaizen ideas? What, if anything, can management do to support the staff? Any evidence that standardized work is not being followed?

Sidebar: One of the two Process Behavior Charts above is showing two signals. Can you identify which chart it is and what the signals are?

LDM helps support our progress through that big PDSA cycle called hoshin kanri or strategy deployment. Remember, part of the Act (/Adjust) phase of a successful PDSA cycle is to sustain the results (for now), write new standardized work, scale up if appropriate, and start teaching to the new standard. This brings a new current state, and the next target condition is identified, initiating a new PDSA cycle of improvement.

In the figure above, the wheel has been moved up the ramp (improvement) through A3 thinking and kaizen. But, there are forces in any system that want to undo that which has been accomplished. Some call it entropy; I think of it as organizational gravity. The function of standardized work is to counter those evil forces by stabilizing and sustaining the new current state.

The role of LDM is to sustain and stabilize ("nail down") standardized work as it is currently written. LDM functions as a "checks and balance" for standardized work, which acts as a wedge to help prevent organizational backsliding. LDM is the setting aside of time on a daily basis to monitor for this potential.

So, to recap, standardized work sustains the current state, and LDM sustains the current standardized work.

Lean Daily Management meetings should take 10 to 20 minutes per day. They are typically done in the mornings, however, they need to be a scheduled, daily priority for all involved. Choose the time that’s best for your practice and team.

All extraneous interruptions should be put on hold for the entirety of the time. During the meeting, a staff member from the department or area of the practice, such as the Hospital Care team, quickly reviews the metrics, status of any countermeasures, new problems that have come up, any cross training efforts, new and ongoing kaizen, etc. with management. The staff member that leads the meeting should rotate from amongst the entire team, so that everyone gets the opportunity to lead the conversation and learn.

As is the Lean perspective, management takes on a teaching and mentoring capacity; asking questions to stimulate A3 thinking, encouraging all efforts and practicing servant leadership.

So, Lean Daily Management accomplishes several things:

1. Gets management to the places where work occurs (go to gemba)
2.  Facilitates conversation and consensus building with staff

3.  Demonstrates management's commitment to the staff

4.  Monitors the metrics that support the True North statement and KPIs

5.  Allows time to encourage and appreciate kaizen efforts

6.  Sustains and audits standardized work
7.  Creates increased engagement of the workers

8.  Show respect for workers

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Also, to answer the sidebar questions, the bottom PBC is showing a signal that needs to be investigated. The first signal is the data point above the upper process limit.The second signal is three or four of the last four data being closer to one of the process limit lines than the average. In the case above, the last five data points are closer to the lower process limit line than the average. In fact, it appears that we may be trending around an entirely new, lower average, which indicates that the whole system has changed somehow. Both of these conditions should have been recognized earlier than now, if they weren't. The next step is root cause analysis and formation of countermeasures, i.e. PDSA problem solving.

The Origins of Lean are Not All Japanese

Over the past few years, while discussing what Lean is with people, I have had one or two of them make comments to the effect that they weren’t interested in learning about anything coming from Japan (or any other foreign country!).

Now, while it is true that Lean did come from Toyota via the Toyota Production System (TPS) and Toyota developed this in Japan, much of what originally went into it came from the good ole' U.S. of A.

There were four primary entities from the United States that had an influence on and are responsible for a very large part of what came to be TPS. They are:

1. Henry Ford and Ford Motor Company
2. W. Edwards Deming 
3. Training Within Industry (TWI)
4. 1950s U.S. grocery stores

Henry Ford

The first influence came from Henry Ford's idea of the assembly line and mass production, allowing the increased manufacturing of identical products by several orders of magnitude. 

These concepts included highly standardized parts, which also allowed for the quick replacement of defective parts with identical replacements, which saved time. But, the mindset was still based on inspecting and repairing defects after the fact instead of preventing defects, as Toyota had already been focusing on. 

Not to mention that most of these defects weren't caught until the whole auto had been built, so sometimes it was just as easy to scrap the car altogether. 

But, what the heck! America was victorious after the war and had plenty of returning workers and plentiful resources. What’s a few thousand defective products and the time and labor to fix the situation? Japan was a defeated country with a scarcity of resources, which required them to be more creative.

Toyota, as well as the rest of the world learned from Ford as he started the mass production assembly line. However, they would tweak it quite a bit in the years to come. And, others would learn that Lean applies in environments that are not moving assembly lines.

W. Edwards Deming 

In recent years, a Toyota executive said:

"There is not a day I don’t think about what Dr. Deming meant to us. Deming is the core of our management.”

W. Edwards Deming was an engineer, mathematical physicist, and statistician during the twentieth century, becoming one of the greatest quality gurus of all time. In 1947, Dr. Deming was asked by the United States to go to Japan to help with the census during the post war restoration efforts. While he was there in that capacity, he gave a series of lectures on quality and process control to the Japanese Union of Scientists and Engineers. They eagerly incorporated his material into their thinking. The Deming Prize is still given out in Japan for examples of the highest quality organizations.

The PDSA (or PDCA) cycle is also known as the Shewhart cycle (or the Deming cycle)

From Dr. Deming, Japan and Toyota learned about building quality into the product at the gemba, the PDCA cycle and systems thinking.

Training Within Industries (TWI)

When the United States decided to enter World War II, most all able bodied men were ushered into military service. This left a large deficit in the workforce population, especially at a time when the military industrial complex was gearing up. In order to replace this workforce, women were recruited to fill these positions. Think of “Rosie the Riveter.”

The problem, of course, was that these new hires had little to no training in industry. Because the need was so immediate, the war department started the Training Within Industry (TWI) program.

Training Within Industry was a predominately volunteer program to help get new workers up to speed as quickly as possible. Many of the TWI trainers were loaned to the project by manufacturers, which continued to pay their salaries.

No manufacturing company was forced to utilize the TWI program. They had to request TWI help, and many did. There were also cases where TWI was used in healthcare.

There were four training programs offered at different times called the Jobs programs. These included the Jobs Instruction (JI) course, the Jobs Methods (JM) course, the Jobs Relations (JR) and, later, the Jobs Safety (JS) course. 

The program was very successful and contributed greatly to the United States being among the victors. When the war was over and the United States was helping to rebuild Japan, the TWI programs were exported. Manufacturers, including Toyota, enthusiastically incorporated the concepts into their own cultures. There is still a copy of an original TWI manual in the Toyota company museum. 

Once the war was over, the War Department ended the TWI program, the men returned to their jobs, the industrial revolution was on its way, resources were plentiful, manufacturers didn't see the need of TWI in their companies and interest in TWI dwindled to almost nothing. In recent years, however, there has been a renewed excitement in the old programs and methods.

The TWI Job Instruction (JI) course
This course was designed to teach supervisors how to teach new workers. These people knew their jobs well and had a lot of experience, but many didn't understand how to teach someone else. This course showed them how to dissect the job into its individual steps and provided them with a standard way of instructing on a step-by-step basis. This was the nidus for TPS's standardized work.

Training cards (as shown above and below) for each of the “J" courses were given to students to constantly refer to when dealing with their workers at their jobsite. This was necessary to protect the uniformity and integrity of the material throughout the project.

The TWI Job Methods (JM) course 

Job Methods taught how to improve the work being done. It was the impetus for kaizen or continuous improvement.

The TWI Job Relations (JR) course

The Job Relations course instructed supervisors how the deal with interpersonal relationships and conflicts. Toyota's commitment to the respect of workers and people came from this information.

These early concepts eventually evolved into Toyota's Improvement Kata and the Coaching  Kata. These are the standardized work of how managers and supervisors teach and mentor their direct reports.

1950s United States Grocery Stores 

Toyota executives who had come to the United States to observe and learn were intrigued by the way our grocery stores replenished their shelves at night with only those items that had sold that day. By the next morning, when the store reopened, the shelves were full for customers to purchase and the cycle repeated. 

Very little inventory was kept in the back of the store which cut down on costs to warehouse a large inventory and the capital tied up in that merchandise. All of this appealed to a small company in a small, recovering country. Just-In-Time thinking was born from this U.S. grocery store concept

While there is definitely an Eastern philosophical hue to the Toyota Production System, the roots of much of the mindset, especially what we would consider the major concepts, originated from the United States. But, keep in mind that Toyota is not the same as every Japanese company. They've worked hard to create a special culture -- they've been willing to learn from other countries. How about you?

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Acknowledgements For My In-Progress Book "Lean Veterinary Practice Management"

I know it is not typical to publish acknowledgments separately, outside of the book and in a public forum. But, it is important for me to do so.

Below, are the acknowledgments for my in-progress book Lean Veterinary Practice Management: Higher Quality, Less Waste, Greater Staff Engagement and Continuous Improvement. 

Acknowledgements 

I have been so fortunate, in my life and career, to have been part of a profession that has been both rewarding (and frustrating!) and self satisfying (and humbling!). A veterinarian is all I ever wanted to be. I never had a backup plan, so it is good that it all worked out!

In the book Honey From the Rock, Lawrence Kushner, writes about Malachim Elyon, ordinary people who, knowingly or unknowingly, act as a messenger from God to intervene in the lives of other ordinary people in their times of need. We all are called for these “errands”, whether we know it or not. I have come to recognize, at least, some of these angel messengers.

I grew up in El Paso, Texas. It was there that I became interested in Veterinary Medicine. My second home, during my high school years, was Northeast Veterinary Clinic, and one of my second “Dads” was Dr. Robert Morrison, of blessed memory. He, more than anyone, helped to solidify my determination to pursue my “calling” of Veterinary Medicine and exemplified, for me, what it truly meant to be a healer for “creatures great and small.” Thank you, Doc.

The veterinarians of El Paso, Texas, are a unique group of individuals. Maybe, because they  were all trying do the same, often difficult and thankless, job in a place that is somewhat isolated in many ways; but mostly because they were just good people!  While we were friendly competitors, we all knew we were colleagues first and foremost, working toward the same honorable goals; we always had each other's “backs.” Of special importance to me were Dr. Bernie Page, Dr. Guy Johnsen, Dr. Robert Rohrbaugh, Dr. Robert Garrick and Dr. Ed Silverman. You all have been very special and very needed in my life.

My dad was a mechanical engineer with an incredible life story. He built a power plant in El Paso, TX, a dam on the Roanoke River in North Carolina, the first radio telescope at Green Bank, West Virginia, and a radiation fishery in Gloucester, Massachusetts, that preserved fish fresh off the boats for more than a year without refrigeration. We owned a toy store later in my youth (not as cool as one might think) and I learned the fundamentals of entrepreneurship and the discipline it takes to be self employed.  

He was my first teacher of the scientific method, of understanding flow, of the Plan-Do-Study-Act cycle (though it wasn't formally taught as such), continual improvement, deep understanding, self reliance, the importance of education, honoring yourself and your family, and of respecting everyone. He was “Lean” before anyone knew that term. Dad, I am so happy that my soul chose our family to be born into. I miss you everyday!

Several years ago, after discovering the Toyota Production System, or Lean, I reached out to Mark Graban. Mark had already firmly established himself as a world-renowned expert in Lean Healthcare. He has authored or co-authored three books: Lean Hospitals, Healthcare Kaizen and The Executive Guide to Healthcare Kaizen, two of which have been awarded the prestigious Shingo Research Award. He acted as Editor for a fourth anthology book, Practicing Lean, which contains practical Lean experiences with contributions from many of his colleagues. He has also published a fifth book dedicated to Process Behavior Charts, a book titled Measures of Success. Mark writes a post almost every day for his blog leanblog.org. He lectures across the globe, holds popular Lean workshops, hosts webinars, is part of the leadership of KaiNexus, a software company, is an advocate for patient safety and has a Lean consulting business. 

As if that weren't enough, he took on a “geeky” veterinarian who knew just enough about Lean to be dangerous, and has been such a friend and mentor to me since that fateful day. He has been my co-author for several articles about Lean in veterinary journals, co-presenter for a lecture on Lean in Veterinary Medicine at a Texas state veterinary conference and continues to edit (i.e. make intelligible) my blog posts at leanvets.com. 

In the ancient and honorable Japanese tradition, Mark is truly a sensei; a master and a teacher. Arigato, Mark.

People often say that they married their soul mates. But, with somewhere around fifty percent of marriages ending in divorce, finding your “true soul mate” evidently takes, at least, two tries. 

That wasn't the case with me. Chris recognized me as soon as she met me! Fortunately, I was aware enough to see the same in her. She was a client of my veterinary practice (imagine that!). Since then she has been my best friend, my wife, my teacher, my guiding light, my sun and my moon. She knows me better than I know myself. Just ask her!

But, it is true. She has an old and gentle soul. I often think of her as the Merlin to my Arthur; my guide in the physical and metaphysical worlds. If there was ever a “messenger of God” sent to someone in need, Chris has been that for me. God has indeed blessed me! I love you more!

In addition, Chris has given me three of the most wonderful children, Paul, Caitlin and Corinne. They have arrived at adulthood with intelligence, common sense, good hearts and the same gentle soul as their mother. Being a father to this group has, almost, been too easy…almost!

For the past seven years my family has indulged my constant obsession with the Toyota Production System and Lean. They have been my de facto sounding boards, proofreaders, editors, “critiquers”, champions and cheer squad. They have learned more about Lean than they ever really wanted to. For this, for their unwavering love and for their perpetual respect, I am truly humbled and so deeply appreciative. Thank you. I love you all.

Chip Ponsford
Dallas, Texas
May 2018

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Lean Veterinary Strategy Deployment (Hoshin kanri)

Hoshin kanri is a Japanese word for strategy deployment. It literally translates to mean “compass management.” It is the process of introducing and aligning the organization’s True North vision down through managers to the frontline staff. It consists of a series of PDSA cycles complete with consensus building (nemawashi) and playing “catchball” along the way.

The first PDSA cycle is undertaken among leadership. It is here that the concept of True North is defined along with the four to six (typically) high-level focus areas and their metrics. 

When looked at as a whole, these few focus areas should completely define your practice. In other words, monitoring the metrics of the focus areas should give you a high-level indication of how the practice is functioning. If these metrics are improving, then the practice should be improving, also. The lower level metrics will compliment these metrics by highlighting the more detailed processes.

This a true PDSA cycle in that all of the stages (Plan, Do, Study, Adjust) are completed and what is eventually chosen is not written in stone. It is an attempt at alignment; high-level standardized work. It is an experiment. If the True North statement turns out to be inadequate in some respect, then leadership simply adjusts and starts a new cycle. A3 reports can follow the process in order to keep stakeholders up to speed.

The second cycle is between leadership (Owners, C-suite, etc.) and supervisors (lead receptionist, lead surgery techs, lead hospital tech, lead groomer, lead boarding tech, etc.). Again, consensus building is of prime interest. This is not the typical management philosophy of “command and control.” It is a typical Lean “bottom-up” endeavor with "catchball" input from leaders. Leadership introduces True North focus areas to the supervisors and, then, mentors and coaches them in order to help them to decide what True North would look like at their level.

and what processes they'll need to monitor in order to help ensure the top focus are metrics are positive. Again, this may be subject to adjustment after a period of experimentation. A3 reports are kept current.

The third cycle is between the lead staff and the frontline workers. It proceeds similarly to the cycle just described.

So, what we now have is is an overall alignment of the practice from leadership through lead techs down to frontline staff. How that looks and what metrics are monitored will vary based on the the different areas of the practice. 

For example, we might have a True North focus area of "Processes Improvement." This applies to everyone. However, at the lead and frontline level, the metrics are different between, for instance, receptionists or exam techs or surgery techs, etc. Their metrics will be determined by what that focus area means to them from their perspectives. 

If all of this is successful, then everyone, from leadership to frontline staff, should have a hold on the same rope, on the same end, pulling in the same direction and at the same time...and winning!








Mark Graban's 4 Hypotheses of Strategy Deployment

Mark has described strategy deployment as a series of four hypotheses in a series of two blog posts - here and here:

 1.  If we focus our improvement efforts and close performance gaps in our four or five True North areas, we will therefore perform well as an organization, this year and into the future.

For example, if we choose Client education, Staff development, Community involvement, Fiscal responsibility and Hospital improvement as our five True North focus areas, then we posit that if we are successful in these areas, the practice as a whole will be successful. In other words, these five areas are the best five areas to monitor in order for the overall practice to be successful. 
Remember, this is your True North statement with your focus areas for your practice with your staff and clients. 

Is this the right True North? We don't know.  But, we will start with these and experiment. If it is determined these are not the best five, we can adjust them and try again. Just like treating our patients. If one diagnosis or treatment is not working, then we “back up" and try again

What are the four or five focus areas that make up your True North and that, if successful, will results in a high probability that the hospital/clinic will be successful overall.

   2.   If we can improve and close our performance gaps in these key performance indicators, we will satisfy our need for improvement in our key focus areas, and therefore will be successful as an organization, overall.

What are the metrics (two or three per focus area) that will show that our focus areas are heading in the right direction (which, in turn, indicates that the whole practice is headed in the right direction).

Are these the right metrics? We don't know, but we'll try them for a while and then evaluate our decision. If they are the right metrics, why? If they aren’t, why not? It is important to deeply understand both of these scenarios in order to learn.

Are these metrics still relevant to your organization and staff?

3. If we actually execute and complete these top X initiatives,  projects, events and A3s, then we will make the greatest strides toward closing the key focus areas (Hypothesis  2) and therefore we'll be more successful in our strategy.

Not everything can be a high priority. It is easy to get sidetracked and pulled off task. You have already prioritized in the last hypothesis. Stay focused. Close the performance gaps in these focus areas in order to get the greatest gains, then you can start over with other focus areas. Err on the side of too few initiatives (so you can actually get something accomplished), rather than too many (and none of them get done or done right). With experience and reflection, you will get more accurate in choosing the number of areas you can tackle without the whole team becoming overburdened. 

4. We actually have the organizational capacity to complete these top X priorities in a year or a given timeframe (and with the right quality).

Do we have the capacity in terms of personnel, resources and capital to actually accomplish these priorities in a timely fashion? If not, then either we obtain them or deselect this priority in favor of another one that can be accomplished at this time.

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You're invited! ... to help me write the first Lean book devoted to veterinary practice

I am ready to start the process of publishing my book on the Toyota Production System,  or Lean, for veterinarians and veterinary staff. This process will use Lean methodology, so I invite everyone who is interested to participate by leaving comments and questions as I go forward. This will be the first book about Lean devoted to the veterinary profession.

I have decided to utilize leanpub.com for this book. The book will initially be published in multiple e-book formats with, hopefully, a paper version later. Lean.pub uses the Lean mindset of starting small, then iterating quickly and updating frequently based on reader feedback. 

So, I will start uploading a new chapter every couple of days to a week. At the same time I will update previous chapters and republish them. I will keep everyone updated through LinkedIn and my blog, www.leanvets.com.

With leanpub.com,  a minimum price and a suggested price are listed. You can get the current version of the book, and all future updates, for either of these prices (or more if you would like for me to get paid more). You decide. At the beginning, the minimum price will be free and suggested price will be $4.99. As more chapters and updates are published, both prices to purchase the book will go up slightly. I anticipate the final suggested price to be around $16.00.

My plan is to use the majority of any proceeds to go towards the continued teaching of Lean principles through lecturing at professional veterinary conventions and the development of staff workshops. Maybe, one day in the future, we can all come together for an annual Lean Veterinary Summit. 

The book covers the majority of the Lean methodology that I have learned over the years of study and presents it from a diagnosis and treatment perspective that veterinarians and their staff are familiar with. Just as our patients are composed of different systems, have a defined state of health and can develope problems which require an objective methodology of diagnosis and treatment, so, in actuality, do our practices. The chapters are designed to follow the same path we traveled as students in veterinary school and our daily diagnostic methods. With your help, as knowledgable and respected stakeholders in our profession, we will be successful with this new beginning; a new paradigm of veterinary practice management. 

Here is the working Table Of Contents:

Preface

Acknowledgements

Introduction

Physiology: Some basics

1. Systems
2. Value
3. Customer
4. Flow
5. Value Stream
6. Just In Time
7. Push vs Pull

Health: True North

Pathology: The 3 “M’s”

1. Waste
2. Overburden
3. Variance

Physical Exam: Establishing the Current State

1. Gemba
2. Value Stream Maps

The Working Diagnosis: Gaps and Root Cause Analysis

1. Gaps = Problems
2. 5 Why Root Cause Analysis

Treatment: The Lean “Medical Bag”

1. Eliminate Wastes
2. Standardized Work
3. Kanban
4. 5S
5. Visual Management
6. Poka yoke
7. Andon Cord

Records: A3 Reports

1. Scientific Method
2. SOAP
3. Deming’s PDCA Cycle
4. A3 Reports
5. Nemawashi: The Importance of Consensus Building

Kaizen: The Environment of Continuous Improvement

Process Behavior Charts: The Voice of the System

Where To Start

Continuing Education

1. Further Reading
2. On the Web

About the Authors

1. E. E. “Chip” Ponsford, III, DVM
2. Mark Graban MS, MBA

So, the first step is choosing a title and sub-title so I can get a couple of book covers designed to choose from.

The current leanpub title is

Lean Veterinary Practice Management (Click here)

Here are my ideas. Notice I have placed a number in front of each title and a letter in front of each sub-title. I have paired a title with a sub-title, but you are welcome to suggest a different combination in the format #/A to make it easy, or an entirely new idea. 

(1) A Strategy of Excellence 

(A) A Lean Guide For Veterinarians 

(2) The Lean Veterinary Practice 

(B)Higher Quality,  Lower Costs, Less Waste, Better Resource Utilization  and Greater Staff Engagement  

(3) Towards Your Ideal Practice 

(C) Making Your Veterinary Practice the Best Your Practice It Can Be

(4) Lean Veterinarians 

(D) The New Science of Veterinary Practice Management 

You can vote by leaving a comment on this post or email me at leanvets@aol.com

Please participate. I value your input, suggestions and questions!