Growing the Lean veterinary practice

Getty Images/Chris J. PriceThink about a backyard garden. Maybe you grow flowers or vegetables or a little of both. Regardless, there are certain elements needed for this endeavor to be productive and fun. While we enjoy getting outside in the sun, tilling the soil, trying new varieties of plants, we don't wish to "work" in the garden more than we have to. We want our garden to be as efficient as possible; we want to work smarter, not harder.

The Toyota Production System (TPS), or Lean, as it has become known, does just that. It helps industries, manufacturers, service organizations-even human hospitals-all over the world to transform their companies to produce more, at a lower cost, with better quality. The system uses fewer resources, engendering greater employee engagement, while at the same time increasing customer satisfaction. Veterinary practice management could similarly benefit.

Today's veterinary practices focus on managing websites, getting seen on social media, acquiring new technologies and developing new "profit centers." These are all important, but the other part is to make sure that the processes and systems within the practice are free of waste and defects, and that they "flow" seamlessly and efficiently. Without scrutinizing and optimizing the processes, without having sound systems in place, new technology and automation only produces defects faster. Maybe we've been too quick to incorporate the "latest and greatest" without attention to basics and keeping up our "garden," so that we get as much out of our practices as possible.

On the next page, we uncover the "14 Principles of the Toyota Way."

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The soil

The soil is the foundation for a good, productive garden. In Lean, the 14 Principles of The Toyota Way are that foundation. If you have good soil, you have the greatest potential for spectacular harvest.

The 14 Principles of The Toyota Way

1. Base your management decisions on a long-term philosophy, even at the expense of short-term goals.

2. Create a continuous process flow to bring problems to the surface.

3. Use "pull" systems to avoid overproduction. (For example: A tray of vaccines in syringes should not be prepped in advance. When pets come in for annual vaccinations it shoudl trigger or "pull" the process of mixing the vaccines and drawing them into syringes at that moment.)

4. Level out the workload (heijunka). (This means to create a regular workflow that dampens variation. It encourages employees to work like the tortoise-steady and on course-not like the hasty erratic hare.)

5. Build a culture of stopping to fix problems to get quality right the first time.

6. Standardized tasks and processes are the foundation for continuous improvement and employee empowerment.

7. Use visual controls so no problems are hidden. (For example, using plastic flags mounted outside exam room doors to signal that the room is in need of cleaning, or is ready for a doctor.)

8. Use only reliable, thoroughly tested technology that serves your people and processes.

9. Grow leaders who thoroughly understand the work, live the principles and teach them to others.

10. Develop exceptional people and teams who follow your company's philosophy.

11. Respect your extended network of partners and suppliers by challenging them and helping them improve.

12. Go and see for yourself to thoroughly understand the situation (Genchi Genbutsu).

13. Make decisions slowly by consensus, thoroughly considering all options; implement decisions rapidly (nemawashi).

14. Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen).

Adapted from The Toyota Way by Jeffrey Liker, McGraw-Hill Publishing, 2004

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The harvest

The harvest is the purpose of the garden. It is the goal. All of the time and energy we put into our garden is to produce the best harvest possible. In Lean, the purpose is value for the customer. By value, Lean means a service or product that the customer, or client, wants and is willing to pay for. For example, the process of getting clients and patients from check-in to exam room must be changed by our work into what the client desires. An expeditious process is of value to the client, but a variation from the process that causes a long wait is of no value to the client. Processes must be efficient and they must be accomplished correctly the first time.

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The weeds

Weeds in our garden are to be avoided. They steal nutrients from the soil. They overcrowd the flowers or vegetables. They require time, energy and resources that otherwise could be devoted to cultivating the products of our garden. The Lean equivalent of weeds is muda or "waste." (See below for more on the forms of muda.) Remember, we want to work smarter, not harder.

Lean differentiates muda into two types. Type I muda is waste that is unnecessary and should be eliminated. Type II muda is necessary waste. An example of Type I muda would be clients waiting to be seen for an excessive amount of time-that's not what the client wants or is willing to pay for. That's not of value. An example of Type II muda is the time required to write accurate and legal medical records; this work does not make the pet healthier but is necessary for any medical practice.

To find weeds one must actually go to the garden. You can't remove weeds by staying in your house. The same is true with finding waste. You must go to where the work is performed (the exam rooms, the waiting room, the kennel, etc.) to see the waste. In Lean, this is called going to gemba-the Japanese word for the "work floor," the actual place where the work is performed. You must see the work as it really is and in real time. When waste is found, it is dealt with immediately by management and staff, together. Everyone has unique and valid perceptions of the cause or causes of the waste and how to best correct it. Lean encourages building a consensus from all involved when deciding how to handle muda. It is wasteful not to utilize the valuable resource and asset that is your team.

The 8 Types of Muda

1. Defects: Doing something incorrectly or spending resources to fix an error.

2. Overproduction: Doing more for the client than the client asked for (or is willing to pay for), or doing something before it's actually required.

3. Transportation: Redundant movement of patients, resources or specimens. 

4. Waiting: Periods of non-production, due to waiting for something or someone.

5. Inventory: Inefficient or excessive inventory.

6. Motion: Unnecessary movement of staff. 

7. Overprocessing: Doing something to a higher level than is necessary or will be utilized. 

8. Staff talent: This is the waste of not utilizing staff effectively-not acknowledging their unique talents, perceptions or potential intellectual contributions. TPS considers workers the most valuable asset in an organization.

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The garden hose

We use a garden hose to deliver water where, when and in the amount needed. It represents a concept in Lean called Just-In-Time (JIT). Traditionally a method of inventory control based on the way U.S. supermarkets replace inventory on the shelves during the night in order to be ready for business the next day, the concept can be utilized for other resources.

JIT is the procuring and delivering of resources, whether drugs, supplies, access to diagnostics, doctors or staff-just exactly where they're needed, when they're needed, and in the amount needed. Anything more or less is muda. More inventory than can be rationally utilized in a timely fashion is wasteful of capital and storage space. Less inventory risks resources not being available when needed. Out-of-stock inventory forces "workarounds" that may be of lesser quality. A doctor's time is limited and his/her skills are unique. These resources should be committed only at the right places, at the time and in the right amount.

One of the basic philosophies of Lean is to make systems as visual as possible. The more visual it is, the less likely muda will be missed. The classic example of JIT is the kanban system. Kanban means "card" or "signal."

An example would be using two bins for microscope slides, placed next to the microscope in the lab area. When one bin is emptied, it is placed aside to be refilled, while the second bin is being used. The empty bin is the visual cue that microscope slides are going to be needed soon and is refilled.

Another example are the plastic flags mounted outside exam room doors, to signal that the room is in need of cleaning, or is ready for a doctor. 

Built into the kanban system is another classic idea of Lean-the idea that resources and products should be "pulled," not "pushed" through the value stream. It is the next downstream step (the customer) that signals the previous step to produce. Lean sees producing excess "work in process"-and then "pushing" it downstream-as wasteful. Instead, patients should "pull" services and products from the hospital and staff. Facilities and services are then adjusted, as needed, in response. In other words, pets coming into the hospital for annual vaccinations "pulls" the process of mixing the vaccines and drawing them into syringes at that moment. Contrary to this, a tray of vaccines in syringes should not be prepared in advance, hoping they get used ("pushed") before they are no longer good.

Dr. Ponsford was a small animal practice owner for 27 years. He is now an associate veterinarian in Dallas. Mark Graban is an author, speaker, and consultant in the field of “Lean healthcare” and has worked with healthcare organizations since 2005 after starting his career in engineering and manufacturing.