Here's the transcript from the recent podcast that Chip Ponsford, DVM (of the LeanVets.com blog) and I did with Samantha Parrett, the Director of Business & Administrative Services at North Carolina State University Veterinary Health Complex.
We know many of you prefer reading over listening… so here you go. I didn't pour over this as a proof reader, so if you see any transcription errors, please post a comment and I'll fix it. Thanks!
Lean Vets Transcript – Podcast #254 – Lean in Veterinary Medicine
Mark Graban: Well Sam, thank you for being our guest here on the podcast today.
Samantha Parrett: You're very welcome.
Mark: Chip, thank you for being here as a very special co-host also, from the veterinary perspective today.
Chip Ponsford: Thank you very much.
Mark: Sam, can you start off by introducing yourself? A little bit about your own background and also a little bit about North Carolina State Veterinary Hospital?
Sam: I'm currently the Director of Business and Administrative Services for the Veterinary Hospital NC State. We currently see about 32,000 sessions per year here at the hospital — Both small and large animals. We introduced “Lean” here at the hospital in 2013 and it's been an interesting journey thus far.
Mark: Have you always been in veterinary medicine? Always at NC State?
Sam: I've been with the hospital for about 12 years now. Previously, I was in the banking world. I came from a Bank Manager position before I entered veterinary medicine.Did a little bit of a 180, not a full 360, but still in the financial world here in the hospital, but working in a lot of different areas and trying to improve the efficiency of our operations here.
Mark: For those who are listening from the context of, I recently learned to start calling this human health care, people who work in hospitals, can you give a little sense of the scope of how many of the employees you have, how many doctors?
Sam: Here in the hospital we have almost two hundred staff members. We work with upwards of three to four hundred veterinarians throughout the college that worked in various positions in the hospital and typically have about a 100 to 120 at a time veterinary students that are working in the hospital on their fourth year of study.With that we also have interns and residents. Have about, I would say about a hundred residents and interns that are also working in the hospital at any given time.
Chip: North Carolina State recently tried a little experiment with Lean. Taiichi Ohno wrote that you start from need. What need prompted you all to consider Lean?
Sam: The very first experiment or transition that we made in Lean actually came from our pharmacy. When we moved into the new Terry Center Small Animal Hospital in 2011, the pharmacy was struggling a little bit in terms of they felt like they had added personnel, but were not making any ground in terms of increasing their output.One of the areas that they felt was really kind of a pinpoint was the chemotherapy prep with the oncology service and so they kind of reached out and said, “Please help us in some way,” and so I talked to them about pioneering the Lean approach with them in conjunction with giving some broader training throughout the hospital for everybody with Lean to try and address that problem for them.
What we did was took about 50 people for the first round doing initial Lean training just on what is Lean and what is Lean approach to problem solving? And included the pharmacy personnel and the oncology personnel that we were going to use for that first Kaizen event in that training and then used that for our first project to get those folks together, map out that process and take a look at where were we duplicating efforts? Where are our wasted moments in that process?
Mark: Sam, how did you first learn about Lean as a possible solution as a way of helping the pharmacy and the hospital more broadly?
Sam: We became aware of Lean through the work that the folks from our College of Engineering Industrial Extension Service on campus were doing with Rex Hospital, the human hospital that's just up the street from us and they had been working with them for a number of years. I became aware of them several years ago probably about nine years ago and approached the hospital administration at that time and college administration about trying to do something here at our hospital.It wasn't the right time for them to receive that and I kept at it over the years and there was finally an opening where I had a couple of services that were willing to dive into it and I was able to find that window of opportunity and a good fronting moment to get that approved and get that started.
Chip: What about Lean were you attracted to? What did it also did that made you think that this might be something that works?
Sam: I think the efficiency stand point. I'm looking at your process. So often when we are trying to solve a problem we make committees and we have meetings and we discuss things endlessly and you never come up with a solution or you wait to implement a solution until its “perfect”.One of the things that I love about Lean is, try it, you know the PDCA cycle what's, to try it. See how it works, tinker with it a bit, let's come up with concrete things.
We are looking at things based on data we are not looking at generalizations where we think this is what's happening. We're looking at what's actually happening. We are getting the people in the room that are actually part of the process. We're not getting all the senior management together to say what we think is happening in the trenches.
We're actually getting the people that are doing the work that are involved in each part of that process. We can see, “OK, what is actually happening, what's the data that backs this up? What can we change about this?” Every single one of these events that I have been part of those, here in hospital, in office, in companies I'm part of on-campus.
Inevitably, one person, further up the line here, is doing something that they think is very, very beneficial to the process. Somebody further down the line is saying, “Oh my gosh, it's totally wrecking my day.”
Sam: It's just fascinating to watch that. I've seen how much you can improve that, even just within those two and three day events. The growth that you can make just from that time that you spend doing that is just exponential and positive.
Mark: Yeah. We are chuckling, I'm chuckling because those are very familiar circumstances from over the human health care side. When you mention committees, people getting wound up about not wanting to try something unless it's perfect. When I hear people say, “It's kind of a red flag to me. I feel like we…” such and such. I'm like, “Oh, wait a minute. Let's go and confirm that. Let's look a date, and let's go and observe.”
Sam: We found that there was one group that we're working with are the personnel and emergency service. One of the theories that they proposed was about, when do you get the owners' permission to draw blood to run the CBC and chemistry panel?They said, “Well, 90 percent of our patients end up running a CBC count at some point. So it'd be easier if you can just do it right away.” Going back and forth about consent, when do you do that? When we're actually reading the numbers, we found out it was 46 percent of those patients are getting those tests done through the emergency service.
When you have an ah-ha , we can show them, “Hey, this is what that's actually happening.” It really makes them go back and think about the decisions that they're making about their process.
Mark: You're talking about understanding the process, collecting data, talking to the customer. What other Lean methodologies were you using in that pharmacy initiative or other work that you were doing early on? What did you find to be helpful?
Sam: Getting the right people in the room. Pharmacy was a small project that we did between the pharmacy and the Oncology.One of the things that came out of that was things that everybody…we all looked at each other and said, “That's common sense.” When they were batching the chemos together, and even batching the oral chemotherapy into that where they weren't delivering those to the oncology service until they were delivering the compounded chemos.
They changed the whole process to where clients can actually come and pick up their pet at noon versus 6:00 PM. In a scenario with a dog with cancer, that's really important to be able to spend some extra time with your animal. There were some really quick, easy fixes with that process.
The next work group is the anesthesia surgery group which is not a quick fix. [laughs] We have been working on for quite some time because it reaches out to all the different services. One of the things that has come out of that is you're not just looking at the processes of the anesthesia group. You're having to look at the process of every service that they work with.
Some of the things that we're finding as far as looking at data, maybe this is true on the human side, there's kind of a data vortex you can also get into or you're getting too much information, and trying to figure out which things to focus on.
One of the things that we recently did with the anesthesia services, in using the anesthesia service to evaluate the efficiency of the services that they are working with, is doing Getty diagrams of their progress when they get a case assigned before they have the patient with them.
How many trips are they making back and forth? Where are they going and why? Once they have the patient, how many trips are they making around the hospital, and gave us some really interesting data in terms of the different services.
Why would you have to go and meet with internal medicine five times before you even pick up the patient? Trying to look at what are we collecting on our checklist, ahead of time, that's missing, that's causing that level of inefficiency before we can even start the process with the patient?
Mark: It just interjected, the one thing I really like about hearing your approach is that you're just focus around a problem that was important. The pharmacy was asking for help. I hear you talking about solving the high level problem but using good problem solving methods from Lean to get toward that problem. As opposed to, I see a lot of people struggle when they get wrapped up around a Lean tool.I propose you wouldn't have gotten this far if you said, “OK, everyone go do 5S.” People might have asked, “Why we are implementing a Lean tool as opposed to solving a problem?” So I like hearing that about your story and your approach there.
Sam: That's what we've done with each of the groups that we're working with on the Lean is we're starting out with a problem. Mapping out a process to identify those problems, and then generating that newspaper list of things to go out and conquer. Determining what are the most important goals and what are things that we can reasonably accomplish, and what are things that are more long-term goals that are going to take a lot more effort?Definitely working from the problem list versus just going out like you are say and kind of blanket doing something like that.
I will say though by taking the approach of opening up that initial training, we ended up getting about a hundred people through the initial training. That was a mixture of staff, faculty as well as house officers, residents, and interns.
That kind of permeated throughout the hospital, so that sprinkled that Lean throughout the hospital, and there are little mini projects that people are doing throughout the hospital.
Some of the ICU technicians that participated in the training but weren't necessarily on one of the work groups started doing 5S in the ICU because they opened the drawer and were horrified suddenly because they didn't do [laughs] the training.
So there are these little pockets of things that are happening that aren't necessarily associated with the work group just because people suddenly had a different view of it based on that training.
Mark: I think it's great because you introduced people to a tool but then they chose to apply it because, like you said, they were horrified by something they now saw differently.
Chip: I have the same thoughts that one of the things that we point out about Lean versus other management systems is the bottom up approach in that these initiatives then become staff initiatives that bubble up from the bottom rather than the leaders, the executive committee or the administrators always having to be the source of ideas and pushing them down on things.I'm really happy to hear that your staff has really bought into this idea, and is taking it further and will continue to take it further.
Sam: I think that's been a huge benefit of this process being used as a problem solving tool in the hospital. As it's given the staff the ability to change their work environment and be a part of that process and empowering them to feel that they can change their environments.It's really been probably one of the biggest things that we've been able to do to improve morale in the hospital. Veterinary medicine is a challenging business emotionally with what the staff have to deal with on a daily basis, in terms of life and death situations.
This is probably been one of the biggest benefits that we've seen in terms of improving morale, it's to give your staff the ability to improve their work environment.
Chip: They can be a positive solution and not the cause of problems?
Sam: Just to say, “Hey, what do you think? Let's get you involved. Let's look at what's happening.” And let you make recommendations and let's let you try things, and we'll help you along the way.We want it to be coming from the people that are actually doing the work instead of 12 people sitting in a room, deciding things that they think might be going on.
Chip: You mentioned that you had some difficulty getting all this started with your top administrators and stuff like that. I'm interested to hear what those feelings were? What were the problems that they were having, and how did you end up facilitating all this and getting this going?
Sam: I think it being a different approach than they had been exposed to before, and not being familiar with it. Particularly with the anesthesia work group this being a problem that we've been trying to solve for 20 years. In terms of being able to get more cases through anesthesia and being more efficient in allocation of those resources.I think it's a level of maybe cynicism [laughs] generated over time that, “Hey, we've been trying to get this solved for years. How is this going to be different?”
I think persistence. I was very persistent in trying to get this started and being able to show results. Also I think getting enough people involved in the initial training so that there were people that got fired up about it and were excited about it and were applying it throughout the hospital.
Showing that it was effective in improving things in the areas that we were working on with it, showing that it was effective in improving morale in the staff. I think showing those results helped to cement the idea in the eyes of the administration.
Mark: I think it's common to have that skepticism or cynicism, like you said. I have seen this in human healthcare people, they're skeptical. They said these problems have been around for a long time.How do we know we're going to solve it? How do we know this program is going to be effective? The other thing I often hear and am wondering, Sam, if you've ran across this. People will point out patients aren't cars, why are you trying to teach us something that they perceive as being about the auto industry? Did you have anyone pointing out the seemingly obvious statement that even large animals aren't cars?
Sam: [laughs] A little bit, but when you can show them that everything is a process and the value stream mapping is hard to argue with that when you can show that and point out the different steps in that.Even something that you would categorize as a simple process when you map it out and there's 35 steps to it. It's really eye opening to people that haven't sat down and looked at that before. You go, “Oh that is a process. I can see where this approach could work when you're doing it that way.”
And not necessarily throwing all the terms at them all the time that are used. The official terms of everything but really breaking it down to the nuts and bolts of what we're doing here, but showing them the data that backs it up.
Administrators love data [laughs] and charts and showing them what's actually happening, and here's an improvement here. We were able to move our caseload up in anesthesia.
One of the goals of the anesthesia, not just getting more cases through but getting them through during business hours. And so we were able to shift that up by about 36 percent to the daytime business hours. Which was a big improvement in trying to get our clinicians out of here at a reasonable time, leaving here at nine o'clock at night.
Chip: You mentioned value stream mapping. I'm interested in value stream mapping. This is a new concept in veterinary medicine. How did you do it? There's lots of different ways or even literature about doing it.There's software. There's just paper and pencil. One of the more common ones that I've seen is the Post-it notes on the wall-type situation. How did you all do your value stream? What was your process in going through that?
Sam: We did the Post-it notes on the big white piece of paper on the wall, and the folks that we work with through the College of Engineering, the Industrial Extension Service, that was their method of doing that and their approach to that.I think that there is a lot of value to putting peoples' hands on things. When they have the ideas that they're shouting out throughout the process of things that we could do better and fix big problem tulips, putting them at the top of your paper. Eventually I would take that information and put it into the computer so that I had an electronic version of that.
We would take a picture of it as well because you don't want to keep rolling out eight feet of white paper to take a look at your diagram [laughs] every day.
I think the value of having that up on the wall through your two or three day process as you're going through that, people really latch on to that and understand that and can put their hands on that. Other people walking by are very interested in what are you doing and they want to come to the room. They want to take a look at that.
There's something very organic about that process. I'm a very technological person, and I love computer programs and things like that. When they first said, “Oh, you're going to do Post-its up on the wall,” I thought, “Gosh, are you guys crazy?”
There's really something valuable about that organic process, and people seem to really latch on to that and get fired up by the Post-its. I will say it's disappointing that they don't make the tulip Post-its anymore. 3M stopped making the Tulips up. That's the only disappointing thing about that.
Mark: Are you saying tulip-shaped Post-it?
Sam: Yes, yes.
Mark: I've never seen those. I'm a Post-it note connoisseur, I thought.[laughter]
Mark: There's something to be said for using Post-it notes that can be much more participatory as opposed to one person controlling a mouse, even if it's being displayed on a projector in a conference room. There's something tactile and more engaging sometimes, I think, about using the Post-it notes and paper. That's the way I've always preferred to do this.
Chip: I have just a little follow up question. I'm interested and curious about what's the difference between — when you internationally did the value stream — what was the difference? What were the gaps between the way you thought the process was working or the way you thought the process was designed to work in the beginning and how it ended up actually flowing?Were there surprises in there that things were not quite as [laughs] efficient as they should have been?
Sam: There were some definite surprises in terms of how long certain things were taking. Any patient that comes through the hospital inevitably is being touched by different services in different areas from the time they come in the door until the time they're discharged.There's multiple groups that are involved in that patient's care throughout the process. Everyone loves to assess who's the backlog in that process, who's the one that's the holdup that's taking too much time?
Everybody loves to say it's radiology or it's pharmacy or it's the person that's on call and didn't call back in time or whoever, it's always somebody that's the problem in that process.
It's fascinating to see where those time lags actually work because it wasn't necessarily where you thought they were. In some cases, we all knew where some of the issues were, but in other cases it was interesting to see that some things were taking incredibly long periods of time. It wasn't where we thought it was.
Those are some aha moments in looking at that and to be able to show some services that sometimes they were the ones that were the gap and looking at ways that we could change how we're structuring that to shorten that gap.
It also had some benefit in looking at the teaching process too which is interesting in a teaching hospital to look at what are the value points for the students, what's the teaching value of certain activities?
For instance, in our small animal emergency service, one of the things that we really chewed upon was is there teaching value when they're rotating through the emergency service in them taking the history by themselves with the client and the patient. And looking at that process because that was one of the things, that that's how it's done in the other services in the daytime services.
In an emergency scenario is that a value added teaching moment for the student. They rearrange that a little bit in terms of the student with the clinician and how they were doing that process which cut down the time that it was taking for the patient to get to the treatment part of things and also increase the teaching value for the student.
Mark: What were some of the results? What was some of the impact from this initial dive into Lean?
Sam: Some of the things that we've been able to achieve with the pharmacy oncology process, we've been able to expedite the delivery of the chemo to the patients and so giving the clients more of a staggered pickup time. It used to be everybody picks up at 6 PM and so now we've been able to stagger those pickup times throughout the day for the oncology patients.It's also been lightening the load on pharmacy in terms of them having to do six chemotherapy preps all at once. That's been a great benefit for them.
With anesthesia surgery, again, we've been able to shift those cases more to the daytime business hours. We're still working on increasing the number of cases per day per week to get those through.
One of the things that we're still working on is the anesthesia schedule distribution in terms of which services they're doing procedures on, which days, and trying to even those resource allocations out.
Again, that's one thing we've discovered that we're not just working on. The key in the anesthesia service is Marlene. We're working on making the entire hospital Marlene's which has been a big piece to chew on.
We revised a lot of our requirements in terms of some of the SOPs, our standard operating procedures, in terms of patient handling in the hospital, what's necessary prior to anesthetic procedure. We've also been able to implement some electronic solutions to make information available throughout the hospital. Patients right now are still on paper medical record for the most part.
One of the issues that we found were people looking for the paper medical record was delaying our patients getting their anesthetic procedure started. We've been able through a combination of our current, what we call our veterinary hospital apps page, as well as the document management system that was implemented.
We've been able to make a lot of the patient information available electronically. Informed consents, lab results, everything like that is available now electronically so that they're not as reliant upon the paper record.
A lot of other kind of side things that necessarily weren't part of the work groups but things that people just started looking at and said, “Well, why are we doing this?” An example of that was we have a radiology information system that even though the images and reports are available electronically, we were still printing those reports and putting them in the paper record because we're still on the paper medical record.
One day we said, “I wonder how many people actually are going to the paper record. How many clinicians are going to the paper record to do that information?” And when we polled everybody, almost no one was referencing it on the paper record. They were all referencing it electronically. We picked a date, we stopped printing those thousands of sheets of paper that we're having to go down the medical records and get filed.
We also were able to, with our competing resources folks, change the way the lab reports get printed out which unfortunately do have to still go in the medical record that they're able now to print them in the terminal digit order that medical records needs to file those reports rather than just coming down randomly and having to be sorted and filed.
So kind of little efficiency things that cause a lot of human hands' work that we were able to look at from a different perceptive through the Lean stuff, “Why are we doing this this way?”
Mark: It's seems like as you progress there's that common theme of identifying problems, solving problems that matter. As those people get better at this, would you agree they get better at identifying problems or prioritizing the right things to solve?
Sam: Absolutely. You know, just questioning looking at what you're doing with New Life and saying, “Why are we doing it this way,” asking the whys. I think they call it the five whys and asking why are we doing it this way not just accepting that that's the way we've always done it or that it can't be changed. Anything could be changed or tweaked and it's again continuous improvement and stressing that to people that nothing's ever really done. You could always make it better.
Mark: Lean has never done podcasts. At some point they have to be done. We have time for just the last couple of questions here. Have you started looking at the idea of Lean as a management system and a culture?I'm curious. Maybe, what you've been reading about that or what you've been thinking about that to transition it from problem solving and projects to what we see. In some cases, in human healthcare people are having that ambition to say, “This is our culture, this is the way we manage.”
Sam: I would like to see it go that direction. We've made some great strides in going that way. We need to have some more resources dedicated to it. Right now, it's essentially me trying to be the major force in that on top of a lot of other responsibilities. I have gone through the Lean Six Sigma Green Belt training.Definitely, we'll need to devote some additional resources to it to move it to more of a culture here and to really have it be part of the management structure. It would be wonderful to see that, and I'm hoping to continue moving in that direction.
I do think looking at it as a culture of continuous improvement where you have the people in the trenches that are doing the work involved in the decision process and making those changes and constantly reassessing and looking for ways to do things better. I think that that could do a lot to improve the positivity of the organization. I think that that is definitely something that we want to strive for.
Mark: It's a huge challenge trying to move toward that, but, like you said, it's continuous improvement. It sounds like you have a lot of forward progress in your journey. That's definitely the thing to celebrate. Chip, I'll leave it to you here for the last question.
Chip: Well, thank you very much. I'm curious about what are the things that has been a problem — with veterinary medicine for as long as I've been in and is still a problem, it's a big talking point right now — is how do we get staff engaged? You mentioned that a little bit. Speak a little bit to that, to those of us that are in not a large teaching hospital or human health care system. Those of us that are just private veterinarians in a private practice.What would you say to us to convince us that Lean is worth at least dipping your toe in?
Sam: I would say that starting from getting them involved and identifying what are the concerns or challenges they're facing in their workplace. Sitting down and doing a value stream map so you're in a, sounds like, a very high volume clinic, walk-in situation so I'm sure that there is some chaotic situations that your staff are dealing with on a daily basis.
Chip: There's lots of chaos.
Sam: [laughs] So getting the staff together and doing a value stream map and you can't map out everything all at once but picking a process and instead saying “Let's take a patient that walks in the door and let's map out that patient's journey through our hospital.” And looking at what happens and having them identify what's going well and what's not going well so that they're coming up with the things that they would like to solve, I think is the best way of getting them engaged.[crosstalk]
Chip: The results that you're seeing with your staff…feel more empowered, engaged, what's been your observations on that?
Sam: They want to work here. They want to come to work every day because they feel like instead of coming in and being frustrated and feeling like there's nothing they can do about it, they come in and they are looking at it from a different perspective. They are looking at it from “What can I do about it? And here are the things that I can change.” and they know that you, as the owner, or the clinician, the manager are listening to them about what things to change.They feel empowered to make a difference in their environment and it's a much different perspective than coming to work frustrated and feeling like you can't do anything about it. They want to come to work because they want to be able to make it better. It's a huge difference in perspective and a huge difference in energy level and a reason to come to work, I think.
Chip: Thank you very much. I hope that we can get some veterinarians to consider this. We've been struggling for a long time in our profession to get some things solved. I really believe that Lean is a paradigm that can help us out quite a bit. I'm so happy to share about you all at North Carolina State showing that this can work in veterinary medicine. I really love that aspect of it. Thank you so much.
Sam: Thank you.
Mark: Thanks, Sam. Actually, I want to sneak in, slip in one more question that Chip had prepared. I think…kind of built on what we were just talking about here. What's possible? Sam, you're in an academic, large hospital setting. What advice would you have for veterinarians who are maybe working in private practice? More like Chip. Do you have any kind of piece of advice for them, to maybe think about their own practice and what Lean could do for them?
Sam: I think just staying positive and don't give up. There's going to be a lot of…for people that aren't familiar with it, there might be some resistance. There tends to be — and I don't know if this is strictly academia or this is also true in private practice or this is just veterinary medicine, in general but sometimes folks would say “Well. We tried that 10 years ago and it didn't work.” or “We had a committee on that 20 years ago they didn't solve anything.”Just being open and positive about it and really teaching the staff about what Lean really is. Being diligent and collecting your data and sharing the data and showing people what's actually happening and involving them in the process, I think can get them on board.
You've got to have a champion that goes in there. You can't have somebody that goes in there that's not a believer themselves. You've got to have that champion to get things going and get people inspired.
Mark: That's great advice. Again, I want to thank Sam Parrett from North Carolina State Veterinary Hospital. Thank you so much for being our guest and sharing your experiences and advice and thoughts with us today.
Sam: My pleasure. Thank you so much.
Chip: Thank you Mark.
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