As Bob Dylan sang in one of his famous songs, "The Times They Are A-Changin'." As O&P colleagues, we need to be able to keep up with the changes. As a person who has been involved in the O&P field for more than 20 years, I have been privileged to witness changes within the industry—from the education side and patient fitting side to managing a large central fabrication division.
As we examine changes in the industry, one of the areas to look at is how healthcare systems are implementing "lean manufacturing" procedures in their system. Lean systems are designed to help companies evaluate what is going on within their businesses, locating problems, and implementing processes to allow the business to run more efficiently. The biggest and most noticeable change with the implementation of lean systems is reduction of waste and improvement in how work flows through the company.
There is far more organization, standardization, and cleanliness as well as a better, more logical approach to how things get accomplished and how problems are solved. Lean thinking is "lean" because it provides a way to do more with less—less human effort, less equipment, less time, and less space—while coming closer to providing customers with exactly what they want. Lean manufacturing is a systematic approach to identifying and eliminating waste (non-value-added activities) through continuous improvement, flowing the product at the pull of the customer, and the pursuit of perfection.
The first principle of lean manufacturing is to specify value. Looking at what the customer wants is absolutely required to sustain the company. Companies exist because their customers feel that they are receiving something of value from them. Therefore, specifying value accurately is the first critical step in lean thinking. An example of this may be a customer (facility or patient) who requests a transtibial prosthesis with a locking pin system, all-carbon fiber socket, setup on titanium components, with an energy-storing foot, delivered in three days.
Identifying the Value Stream
The second principle of lean thinking is to identify the value stream—the set of all the specific actions required to bring a product through the three critical management tasks of any business:
- Problem-solving task: Running from concept through detailed design and engineering to production launch.
- Information management task: Running from order-taking through detailed scheduling to delivery.
- Physical transformation task: Proceeding from raw materials to a finished product in the hands of the customer.
During the identification of the value stream, three types of actions occur:
- Net work: Work that creates value.
- Incidental work: Work that is necessary due to present conditions but creates no value.
- Muda: Actions that create no value as perceived by the customer.
Muda (the Japanese word for "waste") comes in seven forms: processing, waiting, transport, overproduction, stock, movement, and fault (re-work). Identifying and eliminating muda from the manufacturing process will show immediate improvement in the manufacturing, quality, and delivery time of product to your customer. An example of this would be making sure the forms or initial information is gathered with all questions answered and then proceeding to the fabrication process, where all tools and supplies necessary for fabrication are available. Directions for fabrication are available to the technician, and a work center is equipped with only the tools necessary for fabrication.
The third principle of lean thinking—flow—is defined as making all the value-creating steps flow from beginning to end with no stoppages in between.
Flow can be achieved through the following three techniques:
- Focusing on the actual object (product, the order) and never letting it out of sight from beginning to end.
- Ignoring traditional boundaries of job and functions (departments) to form a lean enterprise removing all impediments to the continuous flow of the product.
- Rethinking specific work practices and tools to eliminate backflows, scrap, and stoppages of all sorts so that the production of the specific product can proceed continuously and quickly.
When you manufacture a product, you make it very quickly. An example of this would be looking at any non-value-added time, such as waiting for plaster to set up. What other tasks can be performed during this non-value time? If it takes 15 minutes for plaster to set up, can fabric be cut and PVA bags placed in towels, etc.? This example shows how a job enters the system and flows through the entire manufacturing process. All the steps necessary for manufacturing are examined to identify and eliminate as much as possible any actions that do not add value to the process.
The fourth lean principle is pull. With lean manufacturing, you only produce what is needed, when it is needed, and the quantity needed. In other words, no one upstream should produce any product or service until the downstream customer asks for it. This should keep inventory low, which cuts overhead and space requirements. Companies can look at consolidating vendors to provide materials only when they are needed. Blanket orders can be implemented with suppliers, and deliveries can be scheduled in such a way that you can reduce your warehouse size and space needed in the manufacturing area. One theory holds that you should only have enough materials in-house for a single day's work.
The fifth and final principle is perfection. Perfection is like infinity. Trying to envision it—and getting there—is actually impossible, but the effort to do so provides inspiration and direction essential to making progress. High achievers set specific timetables to accomplish seemingly impossible tasks and then routinely meet or exceed them.
The implementation of lean manufacturing principles in some healthcare systems has resulted in huge reductions in waste and a substantial cost savings surrounding the production, delivery, and quality of the services they provide to patients. As costs of goods, the number of patients, and the cost of re-work due to fabrication errors increases, the implementation of lean thinking can improve your business by leaps and bounds.
Equipment and Materials
Another area that can be examined is materials and equipment. The O&P industry has for several years been involved with CAD systems. These systems have helped practitioners to make better use of their time by allowing them to modify the shape of an image on a computer rather than in a plaster room with hand tools.
Another benefit of a CAD system is the ability to archive and replicate a person's image. With the standard plaster modification process, this ends up being a hit-or-miss activity. This information also can be sent to a milling machine that carves a block of plaster or foam. There are machines that will then auto-form a thermoplastic socket over the carved model.
Currently, this is where the CAD/CAM process ends. What needs to be considered is automated manufacturing. There are a number of options available to companies that choose to become fully automated. While the cost of implementing such systems is often too high for small businesses, there are tools that can be used to improve the speed at which a product is manufactured that will not be as costly as a fully automated system.
Advancements in fabrication materials are also moving forward. Stronger and lighter weight fabrics, temperature-changing fabrics, and advancements in silicones and urethanes are providing customers with a higher quality, more durable device. Although the expense can be high, these types of improvements can be achieved by implementing lean manufacturing techniques.
Another way O&P businesses can move forward and utilize state-of-the-art manufacturing without the outlay of large capital expenses is to use the services of a central fabrication laboratory. The central fabrication laboratory can fabricate your device to your specifications with a high degree of quality and at a competitive cost. For some, a central fabrication laboratory is an attractive alternative to in-house fabrication. With a central fabrication laboratory, there are no fabrication overhead costs. You do not need to worry about material shortages, staff, or the cost of the space and equipment required to fabricate devices. With today's central fabrication services, the communication channels should be open to providing you, the customer, with the highest degree of customer service and quality of product. For years customers have been leery of using central fabrication laboratories because of feeling that the devices they need are being thrown into a big black hole. Practitioners felt like they were losing control of how their prostheses and orthoses were being made and what was happening with them. Today, however, central fabrication labs are closing the "black hole" and instituting new processes such as using web cams and cell phones with cameras to provide timely communication and signature customer service as well as quality, cost-effective devices that are delivered on time.
Weighing the Options
Within the last 20 years there have been huge and exciting changes in the O&P industry. As a business owner and/or practitioner, you need to look at which road to travel is best for you. If it's manufacturing in-house, look at how your business runs. Make sure you are operating as efficiently as possible. Reduce waste and streamline your processes for optimum value. If it's adding state-of-the-art equipment, then make sure you have the volume of work to be cost effective. And finally, if your choice is to utilize a central fabrication laboratory, make sure that it will provide you with excellent customer service, on-time delivery, and a product of the highest quality.
Now I wonder what the next 20 years will bring!
Bill Wilcox has been involved in the O&P profession for more than 20 years in education, patient care, and manufacturing. He is a principal partner with Custom Fit Manufacturing Advisors, a process improvement consulting business in Wisconsin. He can be reached at 651.746.9188.