O&P Fabrication: Getting It Right the First Time

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By Miki Fairley

When it comes to fabricating O&P devices-whether in-house or in a central fabrication facility-it's not always possible to get it right the first time. But it is possible to greatly reduce the number of fabrication re-dos, thus saving labor and materials costs-not to mention getting devices out the door faster for your practitioner customers or patients.

Photograph courtesy of Otto Bock HealthCare

The O&P EDGE spoke with four successful central-fabrication-facility owners and managers about their processes and systems and gathered ideas that you may be able to apply to your own facility, whether you are a practitioner or a central-fabrication owner or manager.

Communication

When it comes to practitioners and central fabrication facilities, there is almost no such thing as too much communication. Bill Clover, vice president of Fabrication Service and Technical Service, Otto Bock HealthCare, Minneapolis, Minnesota, points out an important distinction between two kinds of communication that are necessary in O&P: for off-the-shelf devices, the manufacturer sets the specifications and the practitioner decides if the specifications meets his needs. But for custom fabrication, the customer sets the specifications, and the central fabrication facility must translate the customer's vision into reality.

Thus, the more specifications customers can share to define what they are looking for, the better, says Clover. "For example, say we get an unmodified KAFO cast with the instructions, 'fabricate with drop lock joints, modify cast,' and 'just do standard modifications'-what 'standard modifications' means depends on what school you went to! We need to know, for instance, 'What do you want done over the navicular head and around the malleolus? Do you want us to correct for any varus or valgus deformities? What kind of straps do you want-Velcro®, leather? Do you want buckles? Copper rivets?'"

Bill Clover
Bill Clover

The devil can definitely be in the details. For instance, a customer may say, "That's not what I wanted." And when asked what he wanted, the customer may say, "I wanted white straps, not black," or "You used Speedy rivets; I always use copper rivets."

As with other central fabs, customers of Otto Bock's central fabrication sites in Minneapolis and Orlando, Florida, run the gamut of communication styles. Some provide very detailed specifications; others simply put a cast in a box with a note scribbled on a business card, "Call me."

"Then we start the communication process," Clover says, "corralling the data needed to be able to deliver the device."

Brad Mattear
Brad Mattear

Brad Mattear, general manager of O&P1, Waterloo, Iowa, looks at these "call me" notes as a marketing opportunity and a chance to build a relationship with the customer. He observes that often practitioners are on the road, going from town to town; thus, they are sending casts with tight turnaround times. "I can have one of our technicians talk directly with the practitioner; this kind of communication helps build a relationship."

Direct communication between the customer and the technician working on the device also saves time and eliminates the possibility of muddled communication due to messages going back and forth through a third party, Mattear adds.

Building Relationships

Central fabrication owners and managers agree that building relationships with regular customers-really getting to know them and their preferences-is not only a cornerstone of good communication, it results in higher customer satisfaction.

Tony Wickman
Tony Wickman

To reduce re-dos and meet customers' expectations, "the most important thing is to get as much information up front as we can," says Tony Wickman, president of Freedom Fabrication, Havana, Florida, which focuses on lower-limb orthotics and new-product development. Then, as relationships are built, a dialogue develops; the fabrication facility understands the customer's nomenclature and preferences. "After a while, it's second nature," Wickman says. "The customer can write 'standard AFO' and we know exactly what he means."

Keeping notes and records about regular customers' preferences is a big help too. "We have an overview on file of what each customer likes and dislikes," Wickman says. "For instance, Customer Y likes all the straps copper-riveted, etc."

Knowing your customers and having those relationships can help prevent mistakes-even those that customers make. Mattear recalls a new technician fabricating a device according to the practitioner's work order and a senior technician saying, "I know that's what he wrote, but I know this guy, and this is what he wants." Confirming with the customer showed that the senior technician was correct.

Ben Baker,RTP, pulls a check socket over suction
Ben Baker,RTP, pulls a check socket over suction. Photograph courtesy of O&P1

Otto Bock's fabrication facilities maintain profiles on their customers, which include fabrication preferences. Customers can log onto the company's intranet with a password and see the status of all their work, including jobs that have been shipped, Clover notes. They also can view, update, and change their preference profiles whenever they want.

The national fabrication centers for Hanger Prosthetics & Orthotics, whose headquarters are in Bethesda, Maryland, likewise enable practitioners to log on to an intranet, find their work order online, and check the status of their jobs. They also can complete and e-mail downloaded work orders, adds Jeff Rosen, director of National Fabrication at Orlando and special projects coordinator for Hanger. Hanger has four national fabrication centers: Orlando, Florida; Anaheim, California; Tempe (Phoenix area), Arizona; and Kansas City, Missouri.

A Picture Is Worth 1,000 Words

Another tool to help enhance practitioner/central fab communication is the digital photo. As Rosen says, "We don't have the patient-all we have is what we hope is a good representation in terms of measurements and digital photos." The photos help streamline the conversation when a technician contacts the practitioner about a question or problem regarding a cast or device design.

Jeff Rosen
Jeff Rosen

Otto Bock's fabrication centers take photos from four different views of each job when it arrives and when it leaves, and keeps the photos on record for seven years, Clover notes.

Reducing the Re-do Rate

O&P1, which provides both CAD/CAM and traditional central fabrication, has an enviably low re-do rate. "For our first quarter, we had a 1.8 percent re-do rate in prosthetics and less than 1 percent for orthotics," Mattear says. He attributes this success to careful checking of measurements and a system of checks and balances, with different stages being checked and signed off throughout the fabrication process, as well as to thorough and open communication.

At Freedom Fabrication, "Everything is quality controlled," Wickman says, "and the technicians can stop the process if they see a problem, correcting it before the process moves forward." "A second set of eyes" checks the job at each step, and everyone reads the notes about the job, even if their part is only putting a label on it-making it easier to catch an error that someone else missed, Wickman adds.

Technicians at Hanger's and Otto Bock's facilities also can sound the alarm bell if they see a problem, thus catching it and a possible re-do before more time, labor, and materials have gone into it.

Going Lean for 'Fatter' Positive Results

Both Hanger and Otto Bock have adapted lean manufacturing into their fabrication operations, with notably positive results.

Lean manufacturing, often simply called "lean," is a manufacturing system and philosophy originally developed by Japan's Toyota Motor Company, where it is known as the Toyota Production System (TPS). Many other manufacturers throughout the world have adapted the system to meet their own needs; "therefore, the term 'Lean Manufacturing' is a more generic term and refers to the general principles and further developments of Lean," explains The Lean Manufacturing Handbook, Second Edition, by Tom Epply assisted by Judy Nagengast, published by Continental Design & Engineering, Anderson, Indiana (www.continental-design.com).

A comprehensive discussion of "this quiet revolution that is transforming worldwide manufacturing," as the Continental handbook describes it, is outside the scope of this article, but a basic principle is to eliminate muda, or waste. Waste is defined as anything for which the customer is unwilling to pay or anything that does not, in the customer's view, add value.

The Lean Manufacturing Handbook identifies seven types of waste:

  1. Over-Production: A product that cannot be sold or has to be sold at a reduced price is wasteful. Also, producing product before the customer needs it requires the product to be stored and ties up money in inventory.
  2. Inventory: Excess inventory ties up a great deal of cash, which is wasteful. Stockpiling inventory between processes is wasteful.
  3. Conveyance: Unnecessarily moving a part during the production process is wasteful. It can also cause damage to the part, which creates wasteful rework.
  4. Correction: Having to re-work parts because of manufacturing errors is a large source of waste. Sorting and inspecting parts is also wasteful and can be eliminated by error proofing (designing your processes so that the product can only be produced one way-the correct way-every time).
  5. Motion: Unnecessary or awkward operator motions put undue stress on the body and cause waste. Improvement in this area should result in reduced injury and worker's-compensation claims.
  6. Processing: Unclear customer requirements cause the manufacturer to add unnecessary processes, which add cost to the product.
  7. Waiting: The operator being idle between operations is wasteful. It is acceptable for the machine to wait on the operator, but it is unacceptable for the operator to wait on the machine.

By eliminating waste, you can do more with less:

  • Less capital equipment.
  • Less floor space.
  • Less operator effort.
  • Less direct labor.
  • Less indirect labor.
  • Less inventory.
  • Less lead time.

To see and eliminate waste requires a major shift in mindset. According to the handbook, "The old-school definition of waste is usually described as scrap and rework. To truly implement a lean manufacturing system, you must first change your definition of waste to anything that does not add value to the customer. Once you have changed your mindset, you will see opportunity after opportunity for eliminating waste."

Does Lean Manufacturing Work?

For Hanger and Otto Bock, the answer is "yes." In fact, Hanger's National Fabrication Center in Orlando won the Manufacturers Association of Central Florida (MACF) Manufacturer of the Year Award in 2005, largely due to successful results from implementing lean, Rosen notes.

Hanger quantifies results: each department and work cell is measured monthly for such aspects as on-time deliveries, re-dos, volume per technician, and quantity of jobs that have been brought in. "We have a Team of the Month for whoever had the best metrics," Rosen says. "We also look at things on a yearly basis in terms of our overall performance and achievement of certain goals, and all the facilities have shown dramatic improvement in various areas."

Otto Bock's U.S. facilities have likewise seen positive results, and managers of some of its major fabrication sites in other countries are being brought to Minneapolis in September for a meeting to discuss "lean thinking."

The Lean Journey

Rosen aptly describes "lean" as a journey because it is a process of continuous improvement rather than an end goal.

A key part is to identify the processes that do-and don't-add value to the customer, which is referred to as the "value stream." The value stream is identified by "value mapping"-mapping the flow of material, data, and associated time requirements from initial supplier to end customer for a given business process. Value mapping identifies areas for improvement and sources of waste.

Each morning, team leads at Hanger's National Fabrication Center in Orlando, Florida, meet to discuss the day's plans
Each morning, team leads at Hanger's National Fabrication Center in Orlando, Florida, meet to discuss the day's plans and status of various jobs-a protocol followed at all Hanger National Fabrication Centers. Orlando's Fabrication Center is beta testing the "Re-Do Court" for use by all the facilities if it provides the desired results, according to Jeff Rosen, director of National Fabrication at Orlando and special projects director for Hanger Prosthetics & Orthotics. A device needing a re-do and related paperwork are discussed with a view to problem-solving and preventing recurrences of the problem.

"When we lay out our processes, we are interested in what the customer is willing to pay for because that's where the value is," Clover explains. "For example, if a customer sends a job for a plastic check socket, he just wants to pay for the socket. He doesn't care whether we walk five miles or five feet to a sanding machine or whether we have to pull the plastic three times to get it. The value for him is in getting that socket, so our challenge is how to get the device to the customer faster and how to eliminate or reduce those things that do not add value to the customer."

A good example is Otto Bock's lean journey a few years ago with its custom wheelchair seating. "We determined that one cushion going through the process traveled about five miles inside the building," Clover says. "We evaluated what was really necessary and thus were able to reduce delivery time for that product line from 13 weeks to two weeks-and that's value to the customer."

Both Hanger and Otto Bock's lean systems use cellular manufacturing, which involves work cells-specialized groupings of people, machines, tooling, and materials for more efficient performance of various stages of fabrication. For instance, Hanger's work cells are device-specific for consistency in results: the AFO team makes only AFOs, and the metal team makes only metal devices.

Also contributing to consistent results is Hanger's Central Design Center in Tempe, headed by Stacey Whiteside, CO. The center "provides consistency of modification and allows us to electronically move work across the country to any of our national fab centers, based on capacity," Rosen says. "This, in conjunction with capacity calls at critical junctions in the month, allows for delivery times being kept. The use of standards of manufacturing shared by all national fab centers allows for the same device expectations to be met no matter which national fab center provides the service."

The cellular manufacturing aspect of lean also provides for the delegation of decision-making to the lowest competent level, allowing the team to make decisions in real time, Rosen adds.

Rosen is a passionate advocate of lean and continuous improvement: "It's not thinking 'that's how we've always done it and how we're always going to do it'-I think we've blown the doors off that way of thinking."

Adds Mattear: "We can't forget the past-how the guys from 40-50 years ago built this field on communication, trust, and leadership-but at the same time, we must keep focused on the future." Indeed, fabrication facilities that are masters at combining strategies that have stood the test of time with the latest thinking in quality, efficient manufacturing are well poised to "get it right the first time."

Miki Fairley is a contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at