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Getting Started with Continuous Improvement in Veterinary Practices

Writer's picture: Dr. Karen BoltenDr. Karen Bolten

Four construction workers in safety gear converse at a building site with cranes in the background. One holds a tablet, discussing plans.

Introduction to Continuous Improvement

Continuous Improvement may seem like a simple philosophy - to always do better - and it is; however, it is also an enormous area of business management based on research-backed methodologies, deep evaluation of processes, and sometimes precise statistical control. That said, this area of business management has a lot to offer veterinary medicine. 


Continuous Improvement methodologies and principles exist on a spectrum: from easy-to-implement to highly complex. Some are beyond applicable to veterinary practices, although potentially useful for areas resembling manufacturing, such as production medicine, lab animal medicine, and pharmaceutical production.


Continuous Improvement principles aim to reduce waste, increase efficiencies, and improve outputs. The methods, however, vary greatly, and what may work fantastically for one veterinary practice may cause frustration within another.


On this page, I outline many Continuous Improvement philosophies and methodologies, but that list is overwhelming. Therefore, my recommendations for applying these principles to your veterinary business are below.



Recommendations

Start Small

While Continuous Improvement aims to overhaul the entirety of an organization, every little bit helps, especially if you're overwhelmed by the concept.


Think of a small but impactful topic if you want the easiest way to start on a tiny scale. What is one thing in your organization that keeps going wrong or is causing many headaches? Got it?


Now, you can apply my favorite concept in Continuous Improvement: the poka-yoke. A forewarning that there are a lot of Japanese terms in Continuous Improvement, as they were instrumental in the development of this field, especially Toyota, which has an entire methodology named after it. Poka-yoke means "mistake-proofing." Once you learn about poka-yokes, you'll see them everywhere.


You'll find poka-yokes in your car's automatically deployed airbags and blind spot assist.

Hands working on a circuit board inside a red case with wires. Blue detail on device. Background blurred, tech-focused scene.
Electrical wire color-coding poka-yoke, which you might recognize from high-tension bomb-diffusing movie scenes. Hollywood writers would have a much harder job if all those wires were the same color.

USB ports and electric plugs can only be plugged in one way to prevent electrical issues. If you've ever done electrical work, you know that the wires are color-coded to avoid serious mistakes.


One of the easiest poka-yokes to recognize are the colors used for caution. Designers frequently use yellow in manufacturing plants, roads, and stairs to highlight areas where people may get injured. Fluorescent yellow-green or orange are commonly used for safety gear to ensure humans stand out from inanimate objects.


In your body, one-way valves in your veins help the blood return to your heart, while the automatic coughing reaction helps dispel foreign bodies from your respiratory tract. The sensation of pain is a poka-yoke, letting you know that something is amiss - and the lack thereof can result in serious injuries in people with nerve damage or congenital insensitivity to pain.


In medical practice, checklists are a commonly used poka-yoke to ensure employees complete all items. Researchers have found that when emergency physicians use checklists, the number of missed tasks and the time to complete tasks significantly decreases.


Three white anesthetic vaporizers labeled "HALOTHANE," "SEVOFLURANE," and "ISOFLURANE" with red, yellow, and purple color accents.
Inhalant color-coding is a poka-yoke to prevent accidentally pouring the wrong inhalant into the wrong vaporizer. https://gdhymed.en.made-in-china.com/product/LZJGPuFWZiVX/China-Isoflurane-Halothane-Sevoflurane-Vaporizer-for-Medical-Anesthesia-Machine.html

You'll see many poka-yokes on your anesthesia machines. Perhaps the easiest to discuss is the different colors on isoflurane, sevoflurane, and halothane bottles, caps, and on the machine itself, and also that the vaporizer caps are not interchangeable. These are all safety nets to help decrease the possibility of employees pouring the wrong inhalant into the incorrect vaporizer port. It's not foolproof, but it's an easy solution that has prevented many accidents.


So, how do you create a poka-yoke? It's a simple concept but not necessarily simple to make.

  1. It has to happen automatically. It cannot rely on humans to remember.

  2. It has to be built into the process. If it's not encountered every time during the process, it won't work.

  3. It has to be simple and easy to understand. Refer to the color-coding system.


For more information on poka-yokes, click here.



Incremental Approaches

Want to go bigger but are overwhelmed by the idea? Don’t put too much pressure on yourself to recreate the wheel! As someone who can get easily overwhelmed, not knowing where to start on a big project, I understand, and I cannot emphasize enough that:


You don’t need to overhaul everything at once.


Many methodologies emphasize the idea of “incremental” improvements, such as Gemba KaizenPDCA (Plan-Do-Check-Act), and Agile Methodology. These methods aim to make small changes over time that create significant changes. It’s a process of trial and error until you find the processes that best fit your situation and goals.



What is the End Goal?

Hand holding a brass compass in a forest with autumn foliage. Two diverging paths in the background, creating a sense of adventure and choice.
Both the end goal and the method to get to that goal matter when selecting your Continuous Improvement methods.

I won't stop emphasizing the importance of strategy. You need to understand where you want to go to clarify how you want to get there; otherwise, you will be wasting significant effort on tasks that don’t contribute to your overall plans.


For example, while everyone wants to improve customer satisfaction, there are many different ways to accomplish this. Returning to the basics of clarifying your mission statement, vision statement, and core values will go a long way in helping you figure out the HOW to improve customer satisfaction.


Are you a business that values quality above all else? Then, you should start with quality management principles like Total Quality Management (TQM), Zero Defects Philosophy, or Continuous Process Improvement (CPI).


Are you a company that values employee satisfaction as the method to overall business success? You should focus first on Servant LeadershipKaizenOpen-Book Management, or Appreciative Inquiry (AI).



Prioritize Goals

Once you select your strategic goals, determine your most important one to three goals. What are the "make-or-break" situations you must solve to stay afloat?


Also, be realistic and determine the resources you have to work on these problems. Are you the only person available to handle this project? Do you have other team members available to implement portions of it?


I encourage you to involve team members, as this creates a sense of ownership over driving the changes; however, this is unrealistic in many small practices.


If you are in a small practice, start with just implementing one plan - the most important one that will (hopefully!) create the most improvement. Consider a couple more if more help is available, but I encourage you not to overdo it.


White T-shirt with black text "that wasn't very data-driven of you" centered on a plain gray background.
We're in an evidence-based field, and that should not be limited to just the way you practice medicine. https://www.teepublic.com/t-shirt/48633997-that-wasnt-very-data-driven-of-you

Data is a Must

If you don’t measure it, it didn't happen - or at least, you can’t tell if it's improving. All of these methodologies have some way to quantify where you’re starting versus how far you’ve progressed. Make sure you do this. It’s extra effort, but you need to be able to objectively declare if a choice you’ve made is or is not working. It’s much harder to backtrack once you realize your pathway may not work.



Implementation

To execute the plan, you need to assign an owner. Who is responsible for making sure it happens? You must determine a single person in charge; otherwise, no one is responsible, and no one will implement it.


This person will also be responsible for follow-up, including gathering and presenting data for review later.



Check-In

Determine when you will follow up to determine how your plan has progressed. A quarterly or monthly review may be appropriate, depending on your caseload and the topic.


Circular diagram with arrows labeled Plan (blue), Do (pink), Check (dark blue), Act (light blue) representing a recurring cycle.
One Continuous Improvement technique called "Plan-Do-Check-Act," which clearly shows how important reviewing progressing is.

Did improvement occur?

  • If so, how much? Why did it work?

  • Can you do even better? How?

  • What else can you add to this plan to make it even more effective?


Did it not work?

  • Why? Dive into the why.

  • Don’t go with superficial answers.

  • Ask why several times until you get to the heart of the actual problem.


For example, if you implemented a change in a surgical workflow that didn’t work, you can figure out the problem in several ways.


Ask stakeholders: 
  • Why do you think this process change didn’t work?

  • Where do you see issues that may have gone wrong?


Evaluate those answers on a deeper level:
  • Why do you think (the answer they provided) is causing issues? Ask why again.

  • The answer is where you start to get into the heart of the problem. For example, maybe there is not enough time, employees, protocols, et cetera.


Ask them how they think this underlying issue can be addressed. The solution(s) may be beyond their knowledge base, and the veterinarian in charge should continually evaluate significant problems. Still, these employees often have more insight into the daily issues and best solutions.


As you consider solutions, be sure to reflect honestly on the resource limitations of the business, including financial, human (quantity and skill level), and time. You cannot force a solution that does not address these limitations, but there may be creative solutions around them. You must face them head-on, though.


Flowchart illustrating the cat neutering process. Includes steps like scheduling, surgery prep, and recovery in colorful blocks with solutions.
Process Mapping of cat neuters in a shelter setting

I encourage process mapping if you want to get to the heart of the issue. This technique breaks down all of the steps of routine procedures to sort out bottlenecks, waste, and inefficiencies. It also gives you a roadmap to evaluate where problems may lie.


To the left, I've included an example of a process map I made for cat neuters in a shelter setting. HQHVSN surgeries require high efficiency to create high-volume ability, but not at the risk of patient safety (otherwise, the practice is not high quality).


My goal was to find where the bottlenecks, delays, and other complications were in our workflow, so I laid out the entire process. This exercise was extremely helpful in finding where time was wasted, enabling us to adjust the workflow to accommodate a slightly higher volume within our limited resources.


Conclusion

I want to think that we all ideally want to improve in medicine and our practices continuously, but in reality, it’s easier said than done. Days get busy and slip away, and before you realize it, things are…not great.


Audience sits in a bright conference room focused on a presentation. A person with a blonde ponytail is in the foreground.
Don't limit your CE to medicine. Life-long learning (and more importantly - application of that knowledge) is a rewarding pathway that benefits everyone around you.

Continuous improvement is not just a concept and a methodology. It’s a mindset that you need to build into your workplace culture. All employees need to be on the same page - that this is a practice where we continuously strive to do better, and that requires action and conscientiousness.


Leadership also must permit employees to step up, ask questions, and suggest changes - this is important. Employees need psychological safety to participate in this continuous implementation; otherwise, they will never feel comfortable enough to take ownership of the ideas. You should build continuous improvement into your core values to underlie your commitment to this concept. 


Even if you feel your practice is outdated, you can master the concepts of Continuous Improvement. Start small, work on the most critical strategic tasks first, quantify your progress, assign ownership, and intermittently review progress. Do this repeatedly on individual tasks; eventually, you won’t believe how far you’ve come. 


Just like in medicine, keep learning about continuous improvement principles, as there are a lot of invaluable tools to simplify practice and create higher standards of safety and satisfaction for our patients, clients, and employees.

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