Lean Manufacturing: A Sustainable Approach for O&P Practices

In O&P, manufacturing devices is a part of patient care. There is a method founded on efficiency and optimal standards. It emphasizes using ideas in ways that enable continual change and improvements.

It is known as lean manufacturing, and while it incorporates new-age thinking, the key principles have been around for years.A Japanese philosophy.

Most practices already employ some form of lean manufacturing, sources said, though practitioners may not know it under that term. It was founded by Taiichi Ohno, a Japanese industrial engineer, businessman and founder of the Toyota Production System. He is most known for the term “kaizen,” which is a business philosophy of continuous improvement in working practices and personal efficiency.

In O&P, kaizen, or lean manufacturing, aims to shorten the time between patient need and care. “It is a process that helps us streamline in a way that removes obstacles that could slow [our processes] or make them less efficient,” Don Pierson, CO, CPed, vice president of operations at Arizona AFO, told O&P News.

“It is a culture,” Brad Mattear, LO, CPA, CFO, managing director at Nabtesco Proteor USA, added. “It is the way you run business operations through philosophy.” Nabtesco Proteor USA manufactures both prosthetic and orthotic devices. Mattear said the lean philosophy can improve overall efficiency and reduce waste in a practice, adding that the way it works is simple. “Imagine having a pile of magnet letters that stick on the refrigerator. They are all different colors and letters. There are capitalized letters and lowercase letters,” he said.

“Now, write out [a word] using those letters. You have to find them in the pile, but sooner or later, you will get to the result. What if I took out all the letters that [you do not need]? Your time is cut by 70%. What if I went a step further and I said I want [the word] only in red and I left only the red letters? Makes it even faster.”

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In lean manufacturing, Mattear said everything is placed within reach of the workstation, eliminating the need to find essential tools and cutting production time in more than half.

Implementing lean

Though before a practice can implement lean manufacturing, its leaders should implement structure. “It is all about establishing [collaboration] with staff — those [who] are doing the work day-in and day-out,” Donald E. Katz, MHA, CO/L, FAAOP, told O&P News. “Sometimes we get so busy, [we] do not pause to think about what [we] are doing and why [we] are doing it and the way it is being done,” he said. “Tapping into staff’s expertise as a critical resource [is key in achieving] whatever your goals may be.”

Katz, vice president of facilities and process design at the Texas Scottish Rite Hospital for Children, works from a fully functional orthotic and prosthetic department that custom-fabricates orthoses and prostheses. He also partners with others at the hospital in educating both clinical and non-clinical departments on how to implement lean processes.

At Arizona AFO, Pierson posts visual boards that provide insights on where a project should be along the production line and monitor the daily flow of business.

David Hendricks, CPO, president of Blue Diamond Orthopedic, suggests “kanban,” a Japanese word that translates to “single card.” It refers to a re-order slip, packaging container or computerized system used to obtain additional supplies. When an item begins to run low, an employee takes the re-order card to a manager, who produces the needed amount. The refreshed supply arrives before the original runs out, avoiding any delay in production.

David Hendricks, CPO
David Hendricks
William Carver
William Carver

“It is simple,” Hendricks said. “You put two plastic bins with tags on a shelf. When one bin is emptied, you switch to the other one for production. As soon as it is efficient, you refill the empty bin.”

In order to quickly find those items, William Carver, chief operating officer at College Park Industries, implemented a system he likened to the game Battleship.

“We have [more than] 4,000 individual parts that a person has to pull together to assemble. Trying to train them on what every part is became a difficult task. What we did is created a location system,” he said.

“Instead of saying, ‘Foreheel, 27, left,’ which no one could understand, we say, ‘Rack one, level one, position two.’ It is a bit easier to find rack one, level one, position two on a shelf. It’s numbers.”

Hendricks emphasized the importance of linearity in a production line as a way to improve workflow. “Set up your facility so it is as linear as possible. Raw goods should be stored near where they are received. The first processes should be accomplished near where they are stored, then sub-assemblies should be near there and so forth. The final assembly, which will need to be in the cleanest environment, should be not far from the sub-assemblies and the storage of finished goods should be near the shipping,” he said.

“In a small O&P manufacturer, that linear flow will usually not be in a straight line. It might be more like a jagged circle if you draw it out, but still aim to have the workflow in some sort of linear progression.”


Reducing waste

Sources said in order to further streamline production, practices can focus on reducing waste. Waste can be defined as delays in processing; unnecessary transporting of goods to various storage locations; committing storage space to materials that are not sold; or creating parts that cannot be sold as is or that must be reworked.

A widespread process used for reducing waste is called the 5S, which is built on five principals. The first “S” is for sorting, or removing all unneeded items from the workplace. The second is setting in order, which refers to creating a specific place for everything. The third is shining, or cleaning and inspecting everything in the work area. The fourth is standardizing, which refers to choosing best practices for the work area. The fifth is sustaining, or routine inspection and continuation of the previous principals.

To help with sustainment, Hendricks suggested implementing a schedule. “Have a set schedule at the end of each day or shift. [It] could include charging electric tools, cleaning work stations and other preparations for the next day so the [incoming crew can] start fresh.”

Employee training also can be a benefit, Carver said. He created a training system based his location system. “You talk about less material and less time and things like that, [but] I think it has to start with the implementation of great processes, measurement, work instructions and training. We said, ‘How do we create training to get people to adapt and contribute faster?’ Then we created a standardized method in the way a car has a snowflake that means air conditioner. Everyone knows what that means,” he said.

“[These types of systems] can help people become [more efficient] and make your company scalable. Without instructions and processes, we do not know where our successes came from because we cannot repeat or do the same thing. The only way to double good output is to create great processes, training, coaching and mentorship. Then you can scale your business and repeat results that are favorable.”

Practices also can implement routine audits, which assess and report practice efficiency or lack there of, Carver said. “Lean manufacturing is how you look at processes and measure things. The only way you can and see how you are doing is to understand what your key metrics are, whether it be delivery, cost [or] cycle time,” he said.

“It is like if you are going to lift weights or go for a run, you do not know if you are improving unless you time yourself or you measure how you did. Once you start taking those metrics in, you can start seeing where the breakdown in the process or system is.”

Benefits on business

Don Pierson, CO, CPed
Don Pierson

With the right procedures in place, lean manufacturing can have many benefits, according to Pierson. One is getting all staff on the same page via a standardized, repeatable process. Another is improving efficiency. “You do not work harder, you work more efficiently,” Pierson said. “You are able to get more done.”

When Pierson implemented lean manufacturing for the first time, he said, “It was remarkable. In a short amount of time, we lowered our turn time by over 60%.”

Clearing the lab of unused items was a factor in improving efficiency, he added. “You have a tendency to gather stuff over time. So, when you clear out things that are in the way, it makes the process run smoothly.”

A clean lab can lead to increased revenue, Hendricks said. “The whole idea is to eliminate inefficiencies. If you get rid of emergency ordering of parts where production has to shutdown while you wait, for example, [you] are saving money,” he said. “Your profit is going to [increase] because you will have gotten rid of waste, both in materials and time.”

Donald E. Katz, MHA, CO/L, FAAOP
Donald E. Katz

But increasing revenue should not necessarily be an overarching goal, according to Katz. “As you go along the journey, you are bound to run into some things that make meaningful reductions in cost or increases in income, but that should not be the only goal. If you are doing it right, you are encouraging staff to look at the way they do their work and challenging them to seek out ways in which it can be done differently to make meaningful improvements in services. These can be services not only to our patients, but sometimes equally importantly, to ourselves — the internal customer for work processes.”

When the standard of work is understood more thoroughly by staff, it could increase overall performance. “You are making people happier [in] the way that their day-to-day work is conducted,” Katz said.

“It is not about managers saying, ‘This is the way we are going to do it.’ It is more like, ‘This is the destination we want to reach. We want to see 10% more patients. We want to reduce turnaround by 15%. So how can we do that? How can we do it together?’” he said. “People respond to that. Everybody wants to have a say in how they do their work. It encourages collaboration without question. It encourages a team approach.”


Challenging the status quo

However, there can be challenges in implementing a lean manufacturing process, sources said. A common one is convincing long-tenured staff to accept new procedures.

“I think people are the main challenge,” Carver said. “Changing people’s directives after they have gotten into a pattern is challenging. I remember a supervisor stomped in the corner when I wanted to implement this because the supervisor did not think it would catch on. The supervisor were so used to people just memorizing, the person did not even see the need for standardization and process,” he said.

“If you are a manufacturer and you have been doing something the same way for so long [it] can be hard to change,” Mattear added.

But in order to evolve into more efficient business procedures, sources said, change may be necessary.

Moving ahead

Many practices are catching on, Mattear said. “I think you are starting to see [lean maufacturing] being accepted more. On the surface, you are seeing it on the manufacturing side. Second, you are seeing it on the distribution side. Lastly, you are starting to see it trickle down into the clinical and the fabrication sides,” he said. “Hopefully, the new graduates coming out of school will have a better understanding of how to take these principles and use them in their clinics.”

Katz said that in an uncertain time of audits and regulatory challenges, lean processes could offer a silver lining. “With lean thinking, especially in health care, I like the concept of everyone having two jobs,” he said. “One is to do your work, and the other is to improve your work.

“In O&P, with the diversity of skill-sets that need to come together to improve what we do, utilizing lean principles can be a powerful tool to make work easier by driving out waste in processes, and make meaningful improvements that can improve patient satisfaction, patient outcomes and advance the industry and profession together.” – by Shawn M. Carter

Disclosures: Carver, Hendricks, Katz, Mattear and Pierson report no relevant financial disclosures.

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