Lean Vets

Shawn Wilkie: You’re listening to the veterinary Innovation podcast. You’re listening to the veterinarian innovation podcast. My name is Shawn Wilkie at really excited to be back for another episode Ivan. Why don’t you go ahead and introduce today’s guests.

Meet our guest – Dr. Chip Ponsford

Ivan Zak: Yeah, I’m Ivan Zak and I’m introducing Dr. Chip Ponsford. So we went with chip while ago digitally I should say he is an author of the lien vets a book that this is a topic that is very interesting to me since my dissertation if I will write it will Focused around that but dr. Pawns for he’s known for being a chief of staff at the been filled the Pet Hospital. He’s also an author as I mentioned of a lien Visionary practice management book He’s a speaker at the 2019 a beam a leadership conference, and he’s a graduate from Texas A&M. Do own a hospital in a general practice for 27 years very very excited to have you here. As I said we met digitally this is the first time I’m seeing you you guys can’t see dr. Ponds for but we’re on zoom and for those folks that are unfamiliar with what lean is about and lean methodology. Can you please share and sort of a few words? What is it? And how is it flickable to veterinary medicine? And how did you get inspired to dig into the topic to the degree of writing a book about it?

Explaining the lean methodology

Dr. Chip: It well lean comes from the Toyota production system. This is a system that Toyota auto makers came up with in order to become competitive on a world basis in automobiles. A lot of this stuff actually came from the United States right after World War II and they Incorporated it kind of made it themselves. The word lien is a is a westernized term and it comes from being able to get all the your system. So that’s what the is basically about. It is applicable to any business anywhere and has been applied to two businesses of all different sorts, including manufacturing service Industries a big proponent or big usage of lien has been the human health care area and they’ve seen some tremendous gains using the lean mindset I got involved. With it about seven or eight years ago. I was in the hospital for a short period time for a gallbladder bad gallbladder. And so in my recovery, I decided to start reading I’d always wanted to get a an MBA. I just never wanted to pay for it. So I started reading books and I read about 80 books that first year after my surgery and one of the topics that I came across was leaned in the more I learned about it the more excited I got about it. The more I thought you know, this is exactly the way I think about management. This is exactly the way I think veterinarians think about management and what they’re looking for in a management system and I just it’s just been almost an obsession with him since then I have to say something again to jump in here. Another name for lean is Kaizen if I’m not mistaken, is that correct? No, Kaizen is a part of lean Kaizen means good Improvement or continuous Improvement, which is just art piece of okay. It’s a piece of lee lean is about increasing the value to the client from the clients perspective reducing costs. Increasing quality, utilizing the resources more efficiently. Engaging staff and continuous Improvement. It looks at management and from a systems standpoint lien has a tendency to ask. Why did this happen? Not who did it’s very customer Centric. It is very staff Centric lean sees staff as an asset. In fact lean sees staff as the most important asset that a company an organization has because it’s the only asset typically that that has the ability to appreciate in value over time with training and with experience and and time all these things come together. Each of the little Parts is pretty simple.

Shawn Wilkie: It can get a little bit complicated to put all the pieces of the puzzle together. But once you get it, you don’t think any other way that makes a ton of sense. It’s really interesting to hear that. I was so excited, you know for the recording of This podcast because I was going to show my Arkell Mike eyes end story so unbeknownst to me and I’m going to tell it anyways, even though it’s not exactly what we’re talking about it but unbeknownst to me and I wasn’t, you know, I’ve been through the Toyota method forgot about it and then you know 20 years went by and I had two kids. First name was Kai second name was Zen. So I thought I’d bring up that story. It’s got an interesting so and but I’m also getting an education. It’s really such an honor to have, you know, such a thought leader somebody that’s been involved in this space and somebody that works for one of the coolest organizations and vet Med on our podcast. So, yeah, so welcome again.

Ivan Zak: Yeah. Thanks for that education and explanation. So would they would lean and again I’m a huge fan of Fleeing and and I’ve been studying that for the last sort of year. So again my interest spot because I bumped into it in several areas and and now got dipping my toes into understanding how the human health care works and I totally coolest organizations and vet Med on her podcast. So yeah, so welcome again.

Shawn Wilkie: Yeah thanks for that education and explanation so would they would lean and again I’m a huge fan of fleeing and and I’ve been studying that for the last sort ofWell here is an end and now the kind of intimidation to understanding how the human health care workers. And I totally agree with you. This is sort of the path to engage the front line staff, but can you maybe compared to some other methodologies that that maybe you walked into sort of In This research because to me lean is really about the front line. I’m working with quite a few corporate organizations where we realize that the training and the change has to happen from the top. The level of the of the executive organization and the board of directors, but I never found anything that engages the Frontline staff and I think that lean respond. It’s basically the answer to that and that is that your experience. Is that why you think that that’s applicable to the hospital level or is there any other angles to it?

Dr. Chipp: Well, I think you know the traditional Western Either of them and taylorism is everything top down the leadership decides what’s going to happen? They decide how it’s going to happen to decide when it’s going to happen and it’s forced down the hierarchy to those at the bottom. Lean is much more bottom-up. It’s not completely bottom up. We’re not talking about turning the Asylum over to the prisoners. What we’re talking about is partnering with staff and employees and allowing them to use their intelligence their experience. I mean after all they’re the ones that are dealing with on the gimbal where the action takes place where the production occurs on a day-in and day-out basis. They know the customers. They know the processes they know things that upper management probably doesn’t understand or know about it all so to give them the respect that they deserve for that knowledge and to incorporate them into the process of continually improving and fixing Gets them involved in other words all of a sudden they are not the cause of all the problems. They’re part of the solution. We’re not blaming them anymore your veterinary medicine, maybe some other places as a we’ve been very successful in taking very creative. Very energetic very innocent very enthusiastic staff members that just want to come and help animals and crush them to the point where they don’t want anything else to do with with veterinary medicine and I think lean is the answer to that. They become our partners. They own those improvements that they put in cycle in in our processes and they become our partners instead of somebody to blame all the time for the problems.

Shawn Wilkie: Yes. There is you were as you were talking about that. I just remember the quote from Mark Graves book, which he took as a quote from. Dr. Demian that bed system will defeat good people every time I think that’s really speaks to what you just mentioned. It’s there’s is probably unfamiliar term to most listeners. Can you maybe give us a couple of words and couple terminology of what it lean composed of like what is sort of the day-to-day team that runs lean. What do they do? Like, what does it look like on the level of the hospital for me after all these years of studying and looking at it and trying to decipher it and make it make sense in my own head.

How lean can make a difference

Dr. Chip: That’s where where my book came from and I’ll have to defer to you see how well that that was accomplished but I think lean is really Lee more understandable and more apropos to healthcare industry than it is to manufacturing or service industry or anything else because we are scientifically minded it alleyne is based on the scientific method. So for instance when we see a patient that comes in and it’s got a problem. The first thing that we want to do is we want to establish. What is its current condition? What? Is we do a physical exam? Well, the same thing happens in Li the first thing that we’ve got to do is we’ve got to figure out what is our current condition. Where are we right now and part of that is doing a physical exam. Now, we wouldn’t diagnose an animal without doing a physical exam yet. We diagnose problems and try and fix problems all the time in our practices without doing that. So the physical exam and lean is going to gimbal. This is a a Japanese term it means to go where the work is being done go to the shop floor. If you listened to Japanese newscast, they’ll say instead of I’m so-and-so in New York at the trade Center. They’ll say this is so and so at the Kimba so he’s where the action is going on where the processes are happening. So in our practice we would get together all the different people if they’re our receptionist involved in the process if there’s text involved everybody comes together. This in that patient in that flow of what’s going to be happening come together and they follow five or six or seven patients through for instance annual exams. And then we go back and we map that we put it on paper and we see a lot of times there’s a lot of waste in there that we didn’t realize was going on and that’s the value streams right? You can pose the values, right? That’s the value stream map. This is the physical exam part of lean. Okay. So now we have we know what’s really happening not with the way it’s supposed to be happy not the way we designed it to be happening with the way it’s actually happening warts it all waste defects everything and we can work then and now we can see where we need to be in veterinary medicine. Our goal is to create health. That’s our ideal condition is for a healthy animal quality of life. It wasn’t up to us to Define what the forces but in our practice we get to decide what is ideal, you know, if you think about what would your practice be like if it were ideal if it was perfect. What would that look like? What would that look like as far as staff? What would that look like as far as patients? What would that look like as far as clients? What would that look like as far as Community involvement and giving back to the profession? So you sent this ideal condition what it would be like if it was perfect understanding that we’re never going to get to be perfect, but we So we shoot for then. Somebody said that we pursue perfection hoping that in the in the journey we find excellence. And so that’s the purpose. So now we’ve got our ideal condition. Our true north is what it’s called. We know where we are. We know where we want to be. What are the differences which the problems is dogs at coughing and shouldn’t be coughing. It’s got diarrhea. It shouldn’t be having diarrhea. This practice is got issues with this was got issues with out in shouldn’t have issues with that. This is not happy happening according to our ideal state. So what are those gaps? Where are those problems with our problems list our Master problems list the next step just like it is in veterinary medicine or medicine is to decide. What is the root cause what is the diagnosis? Can we get a common diagnosis that explains everything? We don’t want to fix things a superficial level because it’s not going to last the only way you’re going to get lasting effect from fixing your problems is to fix it at the root cause Pause so we go through a thing and lean called 5y. Well, what’s the problem with why is that happening? Okay. So why is that happening? Okay. Why is that happening? Why is that happening? Why is that happening until we get down to what we consider to be the root cause at that point we can start devising countermeasures or treatments to hopefully fix the problem now, we don’t know if that’s going to work just like we don’t know if a particular antibiotic is going to work to treat an In it in an animal, but we try it’s a place to start and we come back and we analyze how that worked. It worked. Well great we go on in leaned and that becomes now our new standard way of doing work. If it doesn’t work, we re-evaluate and we go back to the process and we come up with other countermeasures and try another experiment until we find something that works. And it’s this interation over and over and over that is Kaizen Kaizen. Is this continuous Improvement day in and day out so that you’re not trying to meet a certain Benchmark set by some organization that says that you should be seeing this number of patients on this number of days and that sort of thing. It doesn’t matter. What somebody else is doing. What matters is what’s happening in your practice. And what matters is that you are better tomorrow than you were yesterday and that you Better next week than you were this week that you are better next month than you are this month that you are continuously improving what the other practices are doing. It doesn’t make any difference. You’re not in competition with them you’re in competition with what you were yesterday. And because you are the expert in your practice, that’s why I lean is I think is so neat. So so cool it teaches you how to have the lean mindset because you’re already the expert in your practice. Your practice is unique. Eek, no other practice has you as the leader as your staff is the staff has your clients is the clients as your location as the location all those things are unique and we can set benchmarks and we can try and make tell practitioners that they should be doing this and they should be doing that and they should be doing it this way. They should be doing it that way but that’s not the case. Every practice is unique and lean is about teaching you how to promote that uniqueness and how to make that uniqueness even more unique and even better than it was yesterday. Scientific method hypothesis do an experiment steady your results analyze your results and make some sort of conclusions about whether it worked or didn’t work. If you didn’t fine now, we know something that didn’t work. We won’t do that again. And the faster that you can go through those iterations the faster that you can find out what works and what doesn’t work. Then the faster you’re going to move forward in the faster. You’re going to improve anybody. That’s any of your competition is going to have to figure out those same questions. You’re going into somewhat of an unknown and the only way to work through an unknown is this trial and error trial and error and trial and error in learning by doing and learning as an organization what works and what doesn’t work in to get where you want to be.

Shawn Wilkie: It sounds like a perfect time for a plug for your book. I think dr. Chip. I’m sure there’s people that are gonna be listening to this thinking to themselves. How can I get started? I’m not a Veterinary practitioner, but I’m a software guy and I mean the the method it just seems so Says steadfast and so true. So right in the middle of the podcast, how do people get your book? Where is the easiest way for them to get it?

Dr. Chipp: The easiest way right now is to Kendall cause all of four dollars and fifty cents to get a Kindle copy. I’m working on the print version to get it formatted and stuff. So it’ll come out on Amazon as a print just not doing it for money. I’m not I’m not this is my little way. I hope of getting back to my profession so that all the new vets and stuff like that that are scared of opening up their practice or whatever. I’m very private practitioner oriented. I don’t want to see the small animal veterinary clinic go the way of the dodo bird and become extinct as we know it in unfortunately, there’s lots of aspects of small. I don’t practice that we’ve lost over the last several years. And I think to some extent we have only ourselves to blame but the book is designed. It starts out with the chapter on physiology. It goes to a chapter on physical exam the goes through pathology the different kinds of waste that we want to be aware of as we look at our practices in our systems in our value streams. The treatments we go into we talked about Kaizen and what that means the other thing that was really interesting to me and learning about the lien was this idea of strategy deployment or the Japanese word for it and I try and stay away from Japanese as much because I think it’s puts a barrier between people, but anyways called potion Connery. What it means is compass management it goes back to this true north. What is your true north? And how do we how do we deploy those ideals and those Concepts throughout the whole practice so that we’re all on the same page. We’re all the same end of the Rope pulling at the same time in the same direction with all of our Force. We’re not working against ourselves and it goes into another aspect that I learned. It’s my stuff is is doing a process Behavior charts, which is a another subject in and of itself super interesting.

I’m going to see if I can shine as a student of yours after reading the book what I liked about this and I think that something that you didn’t mention but but it was kind of assume that all the changes that are implemented at the level of the team and when the decisions are made to do this scientific thinking of experimenting on hypothesis, they’re done by the staff and that that is what is amazing I think about it is that it’s not judgment says go try this. It’s actually uncovering together where the bottlenecks are in the process and where you can eliminate waste make things better and then the staff comes up with the experiments and the scientific nature of it of experimenting failing and then not being blamed for failing. It gives people the creativity and ownership of the processes in the hospitals. And I think that that’s what’s phenomenal about it is that people can own the decisions they can own wins and they can own failures without being blamed. I think so interesting about it. What a concept.

Ivan Zak: Yeah, exactly. So so simple and then I just want to give an example. I was at this lean men at lean thinking conference and human field and they were talking about very simple. It’s not major decisions about the you know, the revenue shift on the price increase it was as simple and human hospitals they had this sign so they had a problem that everybody was waiting in the emergency area. They wanted the patient’s not to urinate before they go to see the doctor because then if they need a urine sample then you can’t collect it. So in this hospital is I think it was in Boston. They have this emergency waiting area where they decided to put a sign on the door next to the bathroom saying do not void before seeing a doctor and it had no effect. And then because they did Lean there then they had this Spanish-speaking nurse that she said. Can you guys put on that door? Do not pee? They said do not void before seeing a doctor but not everybody knows what did not void me? And so they simply change the sign she was so excited about it. She owned that not being science and they put it worked. I know he was he was magic and then she was aligned with management just by owning a little change and not necessarily big change. But what a difference it makes in the day-to-day operation for something like that to happen.

Dr.Chipp: I’ll give you an example of two of the guys ins then again. These are not earth shattering monumental changes that we’re making these our day-to-day little things that make our clients happy provide better service to them or just make our work life easier for us to accomplish on a day-to-day basis. So it’s not so tiring and frustrating. We had a drawer in our Pharmacy and their Pharmacy there wasn’t a lot of it was more of a corridor than it was a room with a lot hinges the TB 3 inches, which we use the 1 cc syringes which we used quite frequently. We’re stack way back at the back of the drawer the insulin syringes which we use to hardly ever threw up at the front. So in order to get him these Rings we had to open the drawer completely the back of it in order to get that syringe and then that just impeded flow back and forth in the pharmacy. So what I did was I took the problem and ran with it on my own and I moved the TB syringes to the front of the drawer put the insulin syringes at the back of the drawer since we don’t use them all that often and that fix the problem now, I guess that didn’t make us millions of dollars. It didn’t save us anything the clients were unaware of that. It wasn’t for them. It was for the staff and in just to make life a little bit easier and getting syringes out of the drawer another example of Kaizen. We were having problems with the control Drug e eeeBook, which is pretty common in that. The right phenobarbital dosage on the right controlled drug log sheet in other words, the 60 milligrams were sometimes being logged on the 30 or the 50 milligram vice versa. Well, I noticed that the label for each of the phenobarbital concentrations was a different color. So we took out the white sheets in the controlled drug log and substituted them for colors that matched the label color of the controlled drug. This is a visual management. I meant concept of lean. So now if they got the phenobarbital that had the blue label, it was just a little bit easier for them to recognize the fact that they were writing on a blue sheet of paper versus a green sheet of paper versus a pink sheet of paper. Now, we didn’t fix all the controlled drug log errors, but we fixed those for that particular drug. Again, we had reached Perfection, but we were a little bit better than we were yesterday.

If lean can be applied to the consolidator model

Ivan Zak: That’s great. The one thing that you touched on that and you know, some people will be listening to this and say oh those are just you know, little changes, which that’s what builds up the The Continuous Improvement. But also you mentioned about the true north. So in couple organization that I work well in smart flow that the software that create and then further in idexx, we implemented also a framework in the management system that’s called traction. It’s a part of the entrepreneurial operating system by genome we know and and then basically what was interesting I was comparing the two and I’m very much driven by implementing an organization’s the vision the mission the core values and then everybody in lining on them when you organization reaches a certain size and I felt it in several organizations over 35, then you can keep the glue of the organization holding together and that particular true north that you mentioned that is something that they recommend but it’s more of a management and executive level framework. What I liked about North Division the principles that everybody in lions on but then also he touches the Frontline staff and it connects them all together and that’s really what composes the entire system. And so I think that it’s so so exciting which leads me to a question now the consolidation on the veterinary Market is very prominent right now. We’re about 20 percent in to consolidate all the practices into these organizations. Do you think that there is a place for lean in the consolidators or is it more of a Sort of of one individual practice methodology and if it does how do you think it may apply?

Dr. Chip: I know of a couple of organizations that are looking at backing off on the micromanagement of individual units within their company and allowing the staff and the managing DVM and stuff to basically manage their office working for a lot of for one of the other National out brand everybody has to be the same so that if you walk into here, it’s the same as you walk in over there. Well, and that’s because they’ve all got the same name, but some of these corporations are not not doing that anymore. Some of these corporations are buying them up and offering the individual practices background help behind the scenes help, you know, they’ll take care of the payroll. They’ll take care of inventory or getting things ordered and shipped and getting best price. Isis and stuff like that, they’ll work with social media and PR and stuff but the practice is keep their saying name. So there’s not this tendency to want to make it everybody the same as everybody else. When as I have felt all along is impossible to do again, we’re looking at unique situations and you know, all these different shaped practices as we’re all trying to put them into a square square hole. I don’t think it works very well. I don’t think it’s sustainable. That way early in the in a podcast. I think first the second episode we had a seal with new consolidation Den espan ol he’s a he’s a CEO of rare breed. Their mission was pretty much that they are helping with the payroll and the marketing and those things but they’re leaving it in the hands off the veterinary practices to make their own improvements and aligning them around sort of their own goals.

Shawn Wilkie: So that’s interesting that you’re saying that there’s more and more of those because they were early stage and I think they are early stage but it will be interesting to see if lean is something that might work for them. It’s also really interesting. I think back to episode 6 when we interviewed, dr. Frank Marshall and it sounds like he’s invented lean maybe without even knowing that he has and I we wanted to ask you if you’ve seen that as well like you go in or have you kind of advised or heard of people that you’re like what you’re doing this now, you just don’t know the name

Dr. Chip: The lien does like I said, I don’t think that a lot of this stuff is all that different than what we’re doing or in veterinary medicine as it is because we are based on scientific thinking I think one of the things that he has done is be able to package it in kind of a complete methodology that allows you to learn it fairly easily the way I look at lean is like giving you a set of Legos. I’m not telling you what to build. I’m just giving you the structure to build whatever you want. However, big you want. However small you want whatever color you want that sort of thing. Then gives the the infrastructure to that. It gives the mindset. It gives the philosophy of doing that though to North the true north is decided by leadership. But after that once it gets deployed down through the levels what metrics and what is decided is important to watch is left to I want a good customer quality. What does that look like at your level as a receptionist? What does good quality to the client look like for a vet tech. What does it look like for a kennel worker? They all have different things. It looks differently from each of the Departments and we’re not telling them what they have to measure what we want is th.t good systems. Yes, we want safety. Yes, we want, you know efficiency all these other things. So it all balances out. We’re not just looking at numbers exactly. That’s why I love the term balanced scorecard and in a in a management of any organization because for the most part, you know, and it’s not new and measuring your business not only by revenue and when you look at most consolidators, they measure ER Revenue profit how many appointments anything that’s leading to how to make money and I think that the challenge invention are medicine on top of all the challenges that we do have with the burnout.