The Toyota Production System and Lean is a complete "philosophy" and management system, so success requires a long-term commitment to all of the concepts, tools and methods. A 5S project here or a kaizen board there does not a Lean initiative and practice make. By implementing the basics of Lean presented here and in previous articles, our hope is that practitioners, managers and staff are intrigued by these ideas, and as an industry and a profession we can all learn more, explore, experiment, discuss and continually improve together.
Value Stream Mapping
A value stream is the sequence of steps and processes from raw materials to the final product—from a sick pet to a healthy one. A current state Value Stream Map (VSM) is a diagram of every step in the value stream as it really occurs; not the way we think it occurs or intended it to occur. The map is then scrutinized to find all the different kinds of muda, eliminating where possible, and then working to create better flow.
While there are many ways to create a value stream map, a less formal, but effective, method is created by using a stack of "sticky" notes and a blank wall. Think about each of the steps in the process you wish to map, or better yet, follow a patient through the process in your hospital. Create one note for each of the steps that occurs from the time the patient is presented for care, until the check-out process has been completed. Be sure to include any waiting times, such as when a patient is placed in a kennel temporarily. Look for any "Type I" waste (an action that has no value, but necessary for the system to function) and remove it from the VSM. Then, methodically evaluate each of the remaining steps.
> Are there any steps whose time could be shortened?
> Are there any that could be performed in parallel, rather than in sequence?
> Are there ways to redirect resources to a specific area in a more timely manner?
Consider alternatives to the status quo:
> Is one staff member better at a particular step than another?
> Is cross training an employee possible for a particular step?
> Would a change in the physical layout of equipment or a work area improve the process?
> Are the sequence of steps logical and the movement of the patient through the value stream smooth?
At the end of this complete exercise, you will have a plan for a new value stream that reduces waste, utilizes resources more effectively, moves the patient through the hospital more efficiently, and generates greater value for the client. It won't be perfect, but it will get better with every iteration of this process.
"5S" embodies a core principle of Lean to make systems visible, so waste is easily seen, making work easier for everybody involved. The five S's stand for (in English and the original Japanese):
1. 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. Do you really need to keep Rabies certificates from 1987?
2. Straighten (Seiton) For everything else that remains, organize it. Adhere to the saying: "A place for everything, and everything in its place." Items used more frequently should be placed closer at hand to save time for staff and veterinarians.
3. Shine (Seiso) Clean up the area. A routine of cleaning the workplace minimizes contamination and infectious disease, creates the opportunity to check equipment and perform timely maintenance, and keeps the hospital in a state that is a source of pride.
4. Systemize (Seiketsu) Do each of the drawers and cabinets, in each of the exam rooms, contain the same supplies, and are they arranged in the same way? Systemizing helps prevent confusion and wasted time looking for items. Provide a "method" to the "madness." Label the drawers, cabinets and bench tops, so everyone knows what is supposed to be there and can easily see if it is not.
5. Sustain (Shitsuke) 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.
The “5 Whys” is one method used to find the root cause of a problem. Many times, the real issue is not readily apparent—you have to "dig" to find it. The idea is to keep asking "why" until a root cause can be identified. The number "five" is somewhat arbitrary, but it implies asking "why" enough times to get to the root cause.
Fixing a more superficial cause will not, ultimately, handle the problem. If you seem to be having the same problems recurring time and again, chances are you have not discovered the root cause. Ask "why" a few more times or brainstorm additional possible causes. Also, be aware that many, if not most, issues are defects in a system, not a person. Lean is about asking “why” and "how," not “who.” Fix the system to prevent anyone from creating muda in the future. This is called poka yoke or "error proofing."
A3 Problem Solving
First, we need to briefly explain the "Plan, Do, Check, Act" Cycle (PDCA). Created by Walter Shewhart at Bell Labs in the 1930s, it was introduced to post World War II Japanese industry by W. Edwards Deming. It was borne out of the scientific method of inquiry—having a problem or question, forming a hypothesis, designing and performing an experiment, analyzing the data and forming a conclusion. More than just a system to solve problems, it is a methodology of deeply understanding the reasons for the problem, to uncover what is known and what is unknown, and of learning, both on an individual and organizational level, in order to prevent reoccurrence in the future.
The PDCA Cycle starts with the "Plan" step. In this step, the problem or situation is thoroughly investigated, from as many perspectives as possible, and with input from anyone who has a stake in the issue. At this point, possible root causes are identified and ideas for solutions, or countermeasures, are formed. The plan for testing and implementing the countermeasures is formulated.
In the "Do" step, the implementation plan is put into action, ideally as a small test of change.
The "Check" step is the evaluation step, where results of the initial implementation experiment are studied and compared to the target vision. If results are not positive, the cycle is begun again, or we adjust.
If the results are positive, the Act step is performed. Creating new policies and procedures completes it.
The PDCA thought process should be developed with input from others—not a single individual working alone. Those involved should handle any differences of opinion or alternative ideas as they are encountered, thus building a consensus along the way. Also, note that 50 percent of the entire report is devoted to the "Plan" stage of PDCA, while the remaining 50 percent is split between the other three stages. This is evidence of the time, energy and importance placed on understanding the problem. It is said that Toyota plans for eleven months and deploys in one.
In Lean, the climate or environment in a veterinary hospital is a culture of kaizen. Kaizen means improvement. For Lean to flourish, everybody needs to be constantly mindful of ways to improve the systems and processes. This culture needs to be as much of what you are as a team and organization, as caring for patients. It needs to be a mindset, and this starts with leaders. All of the other aspects of Lean are of no value without this culture of kaizen. And, it must be sustained. If not, your Lean initiative will be doomed to the compost pile as just another failed efficiency "fad." The graphic to the right shows graphically how major methodologies of Lean fit within an environment of continuous improvement.
You actually already know and have probably practiced kaizen without realizing it. All of the little "tricks" or ideas that are implemented in your hospital that make work easier, less prone to mistakes and safer for your patients and staff, are all kaizen. Every person in the practice, from doctors to managers to veterinary assistants to kennel workers, has improvement ideas and they should be encouraged to share them. Leaders need to create an environment where it’s safe for people to speak up—to point out problems and to share ideas. The byproduct of this culture is staff feeling respected, appreciated and enthusiastic. It engenders team cohesiveness and engagement, and leads to more improvement.
The kaizen board
A kaizen board is a bulletin board hung somewhere in the hospital, visible to the team. It is divided into four columns. The first column is to post new ideas. The second column is for ideas that have been triaged and are waiting to be implemented. The third column is for ideas that are in the process of implementation, and the fourth is for fully implemented kaizens.
The individual ideas are written on small forms that include the problem to be solved, the idea for the solution, the expected improvement, the name of the person who posted it, and the date posted. These forms are placed on the board in the "Idea" column. As kaizens are selected to work on, the form is moved to the "To Do" column, and then to the "Doing" column when work on them actually begins. When it is accomplished and fully in effect, the form is moved to the "Done" column for everyone to see. The person or team who implemented the idea then writes it up in a simple single-page format, often with before and after pictures. The board becomes a source of pride and special recognition for all who participate.
Suggested Lean Books and Resources:
Classic Lean Books
The Machine that Changed the World, by James P. Womack, Daniel T. Jones and Daniel Roos. Free Press. 1990.
Lean Thinking: Banish Waste and Create Wealth in Your Corporation, 2nd Ed., by James P. Womack and Daniel T. Jones. Productivity Press. 2003.
The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer, by Jeffrey K. Liker. McGraw-Hill. 2004.
Toyota Production System: Beyond Large Scale Production, by Taiichi Ohno. Productivity Press (English translation). 1988.
Books on Lean Healthcare
Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, 2nd Ed., by Mark Graban. CRC Press. 2012.
Healthcare Kaizen:Engaging Front-line Staff in Sustainable Continuous Improvement, by Mark Graban and Joseph Schwartz. CRC Press. 2012.
Follow the Learner: The Role of a Leader in Creating a Lean Culture, by Sami Bahri, DDS. Lean Enterprise Institute, Inc. 2009
On the Web
Leanvets at leanvets.com
Lean Enterprise Institute at lei.org
Lean blog at leanblog.org
Dr. Ponsford, a long time enthusiast of Lean, owned and operated a solo, small animal practice for 27 years and was a Chief of Staff for a corporate practice for five years. He is currently an associate veterinarian in Garland, Texas.
Mark Graban is an author, speaker, and consultant in the field of “Lean healthcare.” He has worked with healthcare organizations since 2005 after starting his career in engineering and manufacturing. He resides in San Antonio, Texas.