Lean Veterinary Practice
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An introduction to Lean within veterinary practice presented to Joint Venture Partners of the Vets4Pets group. Apologies for formatting errors during file conversion.
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Lean Veterinary Practice
- 1. Lean: Transforming veterinary care by uncovering opportunities within your greatest asset
- 2. • VetMB from Cambridge in 2000 • Practice owner 2003 - 2006 • MBA from Bath in 2008 • Director of Blue Cross 2008 • Introduced Lean to Blue Cross 2010 • Certified Management Consultant 2011 • Fellow of the Institute of Directors 2012 • theleanvetpractice.com My background 2
- 3. 4 What is lean? Lean is a culture of continuous improvement practiced at every level of the organisation and by every member of the team. It’s a way of working Lean is a way of looking at our daily work and removing any activities which don’t add value to make it better.
- 4. The fathers of lean 5 taiichi ohno 1912 - 1990 henry ford 1863 - 1947 Founder, Ford Motor Company Production engineer at Toyota and father of Toyota Production System
- 5. 6 the toyota production system • Most successful car manufacturer in the world • Greatest number of technical innovations • Highest level of employee satisfaction • Relentless commitment to eliminating waste • Staff makes 1,000,000 improvement suggestions a year. 90% are implemented. But can it work for veterinary medicine?
- 6. The fathers of lean 7 James Womack & Daniel Jones Modern Lean “Founders”
- 7. elements of lean 2. management system Staff’s use of tools is supported by leaders 1. Set of tools Lean provides us with a problem-solving tool kit 3. philosophy Lean becomes part of the workplace culture 8
- 8. 9 set of tools • Root cause analysis • Ishikawa • 5 Whys • SMED • Jidoka • Kata • 5Ws and 1H • Affinity Diagram • Balanced Scorecard • A3 thinking • Andon • PDSA • Takt time • Visual management • Single piece flow • Genchii Genbutsu • Six Sigma • Kaikaku • Kanban • 5S • Value stream mapping • Poka Yoke • 8 wastes • Just-in-time • Kaizen • Heijunka • Hoshin Kanri
- 9. Leadership and management skills are essential for implementing Lean methods and for sustaining improvements. Notably, management needs to: • Develop a sense of trust • Involve the people who do the work • Listen to the opinions made by staff • Empower staff to conduct experiments • Remove organisational barriers • Provide the necessary training • Go to the Gemba management system 10
- 10. Philosophy Simple to define yet challenging to develop, and often requires a significant cultural shift. and Kaizen Respect for People
- 11. kaizen Kaizen = continuous, incremental improvements “A mindset and a way of thinking that’s focused on improving processes while also seeking out ways to improve the lives of people”
- 12. kaizen “If it ain’t broke, don’t fix it!” “If it ain’t broke, find a way of making it even better!” Classic Western thought process: Lean/kaizen thought process:
- 13. Respect for peopleWhat does this mean? • Don’t put people in a broken process • Ensure people have what they need to do their work • Don’t drive cost cutting through layoffs • Don’t overburden people • Have proper staffing levels • Give help and support when needed • Not blaming people for systemic errors • Let people do meaningful work • Let people work to the level they are qualified • Listen and engage people in improvement
- 14. 1 7 how does it work? Lean minimises waste, improves flow and simplifies processes, thus increasing value to the “customer” waste Value
- 16. 2 4 Why lean matters in veterinary care? Employee Engagement Patient Wellbeing/Client Satisfaction Active Clients Financial Results Quality Outcomes
- 17. Who uses lean?
- 19. lean and healthcare • $54 million annual cost reduction through Lean initiatives - Alegent Health, Nebraska • 15% increase in employee engagement scores - St. Boniface Hospital, Manitoba • 29% reduction in length of patient stay - Avera Mckennan, South Dakota • Avoidance of $180 million capital expenditure in new emergency department construction - Seattle Children’s Hospital, Washington • Reduced patient orthopaedic waiting times from 14 weeks to 31 hours - Thedacare, Wisconsin • Inpatient satisfaction scores increased from 68% to 90% - Thedacare, Wisconsin • 48% reduction in readmission rates for COPD cases - St. Margaret Hospital, Pennsylvania
- 20. Who is the “customer”? 2 8 I want a speedy service I want my pet to be treated like a princess I want a a cost- effective service I want to feel better I want to get out of here ASAP! I want to feel listened too
- 21. type definition Value-Added VA Any process or activity meeting the criteria of adding value (left) Non-Value-Added NVA Any process or activity not adding value from the customer’s perspective Necessary Non-Value-Added NNVA A process or activity not of value from the customer’s perspective but deemed necessary value types 32 VA NNVA NVA a typical process
- 22. • Processes are everywhere • A process is a series of steps or activities • Work is made up of processes • Going to Starbucks is a process Processes 33 Drive to Starbucks Park car Walk to building Enter building Place order Collect drink Consume drink Exit building
- 23. • The sequence of steps which deliver the service • Ideally there would be no waste! Value stream 34 Value Value Value Value Value VALUE STREAM
- 24. 3 5 Value Stream Map for Pet Undergoing Operation
- 25. are some of your processes like this? eterinary Practice is a complex system of processes behaving ba
- 28. 43 tool 1 - the 8 wastes
- 29. 4 4 wastes in healthcare “20-30% of healthcare spending is waste” • Over-treatment of patients • Failure to coordinate care • Administrative complexity • Burdensome rules • Fraud Donald Berwick, former administrator of the Centers for Medicare and Medicaid, former President, Institute for Healthcare Improvement “Only 31-34% of nurse time spent with patients” Data from multiple sources, Mark Graban
- 30. 4 5 1. defects Type of Waste (muda) Description Examples Defects Time spent on an activity performed incorrectly, inspecting for errors, or fixing errors Clipping up the wrong leg, giving the wrong dose of medicine or to the wrong patient, filling in forms incorrectly
- 31. 4 6 2. overproduction Type of Waste (muda) Description Examples Overproduction Doing more than what is needed by the customer or doing it sooner than needed Printing off too much paperwork, making up hundreds of puppy packs, too much toothpaste for dentals
- 33. 4 8 3. waiting Type of Waste (muda) Description Examples Waiting Waiting for the next activity when nothing productive is occurring Clients/patients waiting for appointment, vets/nurses waiting for appointments to arrive, waiting for a piece of equipment to be set up
- 34. 4 9 waiting • 62 minutes/day of NVA waiting • Does not include downtime due to lack of clients • Does not include ad hoc tea breaks! • NVA and NNVA combined time will be significantly more! a typical process
- 35. 5 0 waiting • Don’t overlook infrastructure issues • Computer hardware and software is a significant source of waste! • Lots of NNVA and loads of NVA!
- 36. 5 1 4. Non-utilised talent Type of Waste (muda) Description Examples Non-utilised talent Waste of talent when people not engaged, not listening to ideas, not supporting staff’s careers Staff getting burned out and ceasing to give ideas for improvement
- 37. 5 3 5. transport Type of Waste (muda) Description Examples Transport Unnecessary movement of “product” in a system Poor physical layouts requiring excessive transport of drugs, bedding, surgical equipment, specimens, consumables, patients etc.
- 38. 5 4 6. inventory Type of Waste (muda) Description Examples Inventory Excessive inventory causing financial cost, storage and movement costs, spoilage, wastage Too much stock, expired drugs requiring disposal, cupboards bursting with boxes of syringes, food etc
- 39. 5 5 7. motion Type of Waste (muda) Description Examples Motion Unnecessary movement by members of staff Poor layouts requiring lots of to-ing and fro-ing, looking for items, gathering supplies, fetching paperwork of the printer
- 40. 5 6 Spaghetti Diagram Prep Table Work Tops/Cupboards Waste Bin Bandage Bin
- 41. 5 7 solution
- 42. 5 8 8. extra-processing Type of Waste (muda) Description Examples Extra-processing Doing work that is not valued by the customer or caused by definitions of quality that are not aligned with patient needs Performing too many diagnostic tests, over- prescribing antibiotics and other unnecessary meds Note: don’t get hung up whether a waste is overproduction or extra-processing - it doesn’t matter as it’s all muda!
- 43. 5 9
- 44. A Lean Problem 60 can you find the man in the beans?
- 45. A Lean Problem 61 “The most dangerous kind of waste is the waste we do not recognise” Dr. Shigeo Shingo
- 46. 6 3
- 47. 6 4 value stream versions What you think it is What it should be What it actually is What it could be
- 48. 6 5 Value Stream Map for Pet Undergoing Operation
- 49. 201 8 Level 2 Generalised adoption of Lean culture, positively impacting practice performance metrics 202 0 - 220 Level 3 Self-sufficient Lean enterprise, cultural and performance transformation, operating at benchmark performance level 201 7 Level 1 Beginning to stimulate a Lean culture with localised improvements visible 201 6 Level 0 Traditional non-Lean environment Yeovil Lean level 66
- 50. 6 7 WHAT MIGHT YOU SEE? Kanban 5s Standardisation Heijunka Value Streams Visual Management
- 55. 72 Project Complexity Micro Lean Macro Lean Everyday 2-3 times/year lean PROJECTS
- 56. 7 3 HR m m n b j b jH R jjjj H R kj n kj n Sort Set Shine Standardise Sustain • Sort • Set (set-in-order) • Shine • Standardise • Sustain 5s
- 57. 7 4 HR m m n b j b jH R jjjj H R kj n kj n Sort Set Shine Standardise Sustain • Sort • Set (set-in-order) • Shine • Standardise • Sustain sort Determine what’s needed from what isn’t and get rid of the latter. Red tag anything you’re not sure about
- 58. 7 5 5s - Red tags
- 59. 7 6 Needs 5s!
- 61. 7 8 HR m m n b j b jH R jjjj H R kj n kj n Sort Set Shine Standardise Sustain • Sort • Set (set-in-order) • Shine • Standardise • Sustain set
- 62. what’s missing? 3 4 5 8 28 6 10 18 17 15 13 27 25 23 30 29 1
- 63. What’s missing? 1 3 4 5 6 7 8 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 27 28 29 30
- 67. 8 4 5s example
- 68. 8 5 5s example
- 69. 8 6 HR m m n b j b jH R jjjj H R kj n kj n Sort Set Shine Standardise Sustain • Sort • Set (set-in-order) • Shine • Standardise • Sustain Shine Make the practice “shine” by thoroughly cleaning all essential items, equipment and surfaces
- 70. 8 7 shining!
- 72. 8 9 HR m m n b j b jH R jjjj H R kj n kj n Sort Set Shine Standardise Sustain • Sort • Set (set-in-order) • Shine • Standardise • Sustain Standardise Standardise to make the first 3 steps reproducible
- 73. 9 0 HR m m n b j b jH R jjjj H R kj n kj n Sort Set Shine Standardise Sustain • Sort • Set (set-in-order) • Shine • Standardise • Sustain Sustain Embrace the Lean philosophy to not only maintain standards but to continuously improve upon them
- 76. many other initiatives • Standardisation • PDCA/A3 Thinking • Poka yoke • Andon • Quality at source • SMED • Mentoring • SMART objectives • Visual Management • Huddles higher quality greater customer satisfaction reduced cost engaged staff
- 77. 9 4 financials 2017 Results Net Sales 3% increase Payroll as % Sales 3% decrease Locum Costs 63% decrease Stock 16% decrease Overhead as % Net Sales 16% decrease Debt £12,000 reclaimed EBITDA deficit halved Figures based on 2016 v 2017 averages of Periods 4-6
- 78. 9 5 Why lean matters in veterinary care? Employee Engagement Patient Wellbeing/Client Satisfaction Active Clients Financial Results Quality Outcomes
- 79. 9 6 lean resources • The Lean Vet Practice website: https://www.theleanvetpractice.com • Graban M., Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, (3rd edition, June 2016) • Podcast: Gemba Academy Podcast • Podcast: Lean Healthcare Exchange • The Lean Enterprise Academy: https://www.leanuk.org • Institute for Healthcare Improvement: https://ihi.org
- 80. please CONTACT ME THANK YOU 97 phone: 07871 062 995 EMAIL: theleanvetpractice@gmail.com Value QualityValue Stream Customer Kanban Respect Philosophy Management System 5S 8 Wastes Cost Standardised Work