European Journal of Radiology 81 (2012) e47–e52

Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Applying value stream mapping techniques to eliminate non-value-added waste

for the procurement of endovascular stents
Ulf K. Teichgräber ∗ , Maximilian de Bucourt
Department of Radiology, Charité University Hospital Berlin, Charitépaltz 1, 10117 Berlin, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Ojectives: To eliminate non-value-adding (NVA) waste for the procurement of endovascular stents in
Received 12 October 2010 interventional radiology services by applying value stream mapping (VSM).
Accepted 17 December 2010 Materials and methods: The Lean manufacturing technique was used to analyze the process of material
and information flow currently required to direct endovascular stents from external suppliers to patients.
Keywords: Based on a decision point analysis for the procurement of stents in the hospital, a present state VSM was
Toyota Production Systems
drawn. After assessment of the current status VSM and progressive elimination of unnecessary NVA
Procurement
waste, a future state VSM was drawn.
Endovascular stents
Value stream mapping
Results: The current state VSM demonstrated that out of 13 processes for the procurement of stents only
2 processes were value-adding. Out of the NVA processes 5 processes were unnecessary NVA activities,
which could be eliminated. The decision point analysis demonstrated that the procurement of stents was
mainly a forecast driven push system. The future state VSM applies a pull inventory control system to
trigger the movement of a unit after withdrawal by using a consignment stock.
Conclusion: VSM is a visualization tool for the supply chain and value stream, based on the Toyota
Production System and greatly assists in successfully implementing a Lean system.
© 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction relationships and to identify hidden waste. Table 1 depicts key facts
on VSM.
Early initiatives carried out in industry to establish supply chain
developing programs have shown that it is necessary to map value-
2. Materials and methods
adding processes. By eliminating non-value-adding (NVA) factors
and creating an overall smoother process, products and services
2.1. Area of application and outline of an implementation plan of
become more valuable to the consumer as well as more competitive
the value stream mapping technique
to rivals on a market. These economic approaches are increasingly
applied in numerous medical settings [1–5].
The VSM technique was applied at a university interventional
The car manufacturer Toyota was the first company to use
radiology department to eliminate non-value-adding waste in the
value stream mapping (VSM) techniques to implement Lean con-
process of endovascular stent procurement.
cepts and tools. The purpose of VSM is to minimize waste that
The focus was set to endovascular stents. They account only for
prevents a smooth, continuous flow of products and informa-
a small amount of overall items used (ca. 15%) while accounting
tion throughout a value stream [6]. A value stream displays the
for the majority of value (ca. 80%) processed during the medical
set of activities (and their respective value) involved to create
intervention. There are various stent differences e.g. in size, length,
a product or provide a service. Value stream mapping can be
material and functionality, thus rendering a voluminous and very
defined as a lean manufacturing technique used to analyze the
cost intensive stock keeping for hospitals necessary. Table 2 depicts
flow of materials and information currently required to forward
an outline of the VSM implementation plan pursued.
a product or service to a consumer [7]. Using pencil and paper or
computer assistance, visualization serves as a tool to convey infor-
mation about processes and interactions, to understand complex 2.2. Waste identification

In order to objectify the identification of “waste,” one key con-

cept in the Toyota Production System (TPS) referred to as the
∗ Corresponding author. Tel.: +49 30 450 527144; fax: +49 30 450 557907. “seven wastes” (1. overproduction, 2. unnecessary transportation,
E-mail address: ulf.teichgraeber@charite.de (U.K. Teichgräber). 3. inventory, 4. motion, 5. defects, 6. over-processing, 7. waiting)

0720-048X/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2010.12.045
e48 U.K. Teichgräber, M. de Bucourt / European Journal of Radiology 81 (2012) e47–e52

Table 1 Table 4
Key facts on VSM. Factors considered before finalizing the future state VSM.

Value stream mapping # Factor

The VSM technique originates from the Toyota Production System
1. Review the present state VSM
It is renowned for its focus on reduction of the original Toyota ‘seven
2. Calculation of takt time
wastes’ in order to improve overall customer value
3. Identification of bottleneck processes
VSM is a Lean technique that is used to analyze the flow of material
4. Identification of lot size and setup opportunities
and information required to direct a product or service to the customer
5. Identification of potential work cells
6. Identification and definition of signaling systems
triggering just-in-time action
was applied and adapted (Table 3) to the specific clinical setting. 7. Establishing scheduling methods
Each procedural step was reviewed and inspected for possible 8. Calculation of lead and cycle times
occurrence of waste, especially unnecessary NVA waste. 9. Identification of specific process improvement

2.3. Mapping the current state

two processes were genuine value-adding processes:
The current state VSM was created according to the standard of
• The supplier of stents (process no. 1).
value stream mapping using the icons depicted in the glossary of
• The procedure of stent implantation (process no. 9).
items (Fig. 1).

2.4. Mapping the future state Out of the remaining processes, five were identified as unnecessary,
six as necessary NVA activities:
As the future state map is generally subject to change as Unnecessary NVA waste
work progresses, each of the nine factors in Table 4 were consid-
ered with considerable detailing before the future state VSM was • incoming goods department (3),
finalized. • central storage (4),
• inspection (5),
• in-hospital package and transportation (6),
3. Results
• procurement department (13).
3.1. Creation of the current state value stream map
Necessary NVA wastes
The current state VSM was created and graphically organized
(Fig. 1), considering thirteen procedural steps (Table 5). • transportation (2),
• superintendent (chief nurse) (7),
3.2. Assessment of the current state value stream map • local departmental stock keeping (8),
• financial officer (10),
An assessment of the current state VSM (Fig. 1) demonstrated • department head (11),
that out of thirteen processes for the procurement of stents only • controlling (12).

Table 2
Outline of the implementation plan of the VSM technique.

Step Task

1. Identify the procurement of stents as the main product, taking into consideration the relevant product family, necessary supplemental materials and services
2. Create a current state VSM, which depicts the process with current steps, delays, and information flows
3. Assess the current state VSM in order to create flow by eliminating waste, especially unnecessary NVA waste
4. Create a future state VSM with superior flow potential
5. Implement the future state VSM

Table 3
Adaptation of the ‘seven wastes’ to the clinical setting of interventional radiology.

The ‘seven wastes’ according to TPS Exemplary adaptation to the clinical setting

1. Overproduction Not typically applicable in health care environment; a patient may be treated too early or unnecessarily, which also includes
an ethical dilemma. If too many patients are treated and budget is exceeded, there may be no reimbursement. In the given
scenario, stent implementation requires a medical indication and validation. Therefore this type of waste was not considered
applicable
2. Waiting Occurs in multiple situations: delivery of goods, missing material (e.g. stents), occupied operation rooms, scheduling mistake
(e.g. nurse, technician, physician or patient not arriving in time)
3. Transportation In this scenario a stent is demanded, delivered to the hospital from an external supplier, transported in-hospital and then held
in stock, but not jet implanted into a patient’s vessel
4. Inappropriate processing Often referred to as ‘using a sledgehammer to crack a nut.’ Smaller, more flexible but also low-cost automation equipment
should be used whenever possible. Order, delivery or implementation of inaccurate stents as well as excess personnel or
material used for the process are types of inappropriate processing
5. Unnecessary inventory Too many stents on stock (excess inventory). Excess inventory may impede identification of shortfalls such as late deliveries
form suppliers and long setup times
6. Unnecessary motion Excess movement of an operator. This waste is related to ergonomics e.g. long distance walking to obtain supplies or sorting
through an unorganized or malpositioned stock
7. Defects Defective stents resulting in rework represent a tremendous cost, including associated costs of re-inspecting, rescheduling
and capacity loss
 U.K. Teichgräber, M. de Bucourt / European Journal of Radiology 81 (2012) e47–e52 e49

Fig. 1. Current state value stream map for the procurement of Stents.

Support functions such as inventory control and transportation
may be considered necessary but by definition do not convert mate-
rial into a customer product. In this scenario the stent implantation
is the product and the customer is the patient or the referring physi-
cian.
only 1.92% was used for value-adding processes. Only 15.4% of the
human resources involved in the procurement process were per-
forming value-adding activities.
3.4. Current state decision point analysis

3.3. Current state process activity mapping
In the process activity mapping of the procurement of stents
(Table 6) out of 13 work steps only three were operational. All other
activities involved either inspection (n = 6), or stock keeping (n = 2)
or transportation (n = 2); furthermore, a total of n = 4 processes were
administrative. Regarding the time spent for procurement of stents,
A decision point analysis assisted in determining the transition
point in the supply chain where demand-pull gives way to forecast-
driven push. It demonstrated that the procurement of stents in the
conventional inventory control and scheduling manner was mainly
a forecast driven push system (Fig. 2). A pull character was only
existent for the final operative process of stent withdrawal from
the departmental storage.

Table 5
Procedural steps of the current state VSM.

Step Process/organizational unit/institution Comment

1. Supplier Manufacturer and distributor for endovascular stents

2. Transportation to the hospital Usually the supplier guarantees delivery of stents within 24 h after order receipt
3. Incoming goods department Receiving stents form supplier. First inspection (control of order specifications)
4. Central storage In-hospital warehouse
5. Inspection Inspection of stents before leaving the storage focusing on defective packaging, destruction of
sterile packaging, control of product ID and expiration dates
6. Within hospital package Packaging and transportation in-hospital. The central storage is serving three university hospital
locations in town. Therefore transportation distance can account up to 12 km
7. Superintendent Accepts delivery of stents, organizes departmental storage, receives information from the
angiography room on current stent usage, provides information for the financial officer and orders
stents at the procurement department
8. Departmental storage Local supermarket for stents
9. Procedure (stent implantation) The room where the stent placement is performed. A stand-by nurse retrieves the stent from the
departmental storage upon physicians order
10. Department financial officer Adherence of the departmental budget, communication with controlling department
11. Clinical department head Responsible for clinical concerns and management of the department
12. Controlling department Interacts by ruling, supervising, regulating, managing, restraining, etc.
13. Procurement department Negotiates with vendors for the lowest costs and incentives, analyzes market price and product
mix, checks for competitiveness of the “stent market”s, reports to the controlling department
e50 U.K. Teichgräber, M. de Bucourt / European Journal of Radiology 81 (2012) e47–e52

Table 6
Process activity mapping of the procurement of stents.

Step Flow typea Distance (m) Time (Hrs) Manpower Comments

1. Supplier O 24 1 Reservoir
2. Transportation to Hospital T –b 2 2
3. Incoming goods I 0.1 4
4. Central Storage S 100 0.1 4 Reservoir
5. Inspection I 0.1 2
6. Package T 8000 2 1
7. Superintendent I 0.5 2 Both operator and administrator
8. Department Storage S 30 Dedicated Reservoir
9. Procedure O 1 3
10. Financial officer I 0.1 1 Administrator
11. Department Head I 0.01 1 Administrator
12. Controlling I 0.01 2 Administrator
13. Procurement O 48 3 Administrator
Total 8130 77.92 26
Value-adding (%) 1.92% 15.4%
Operators 1.5 4
a
O = Operation, T = Transportation, I = Inspection, S = Store, D = Delay.
b
Transport distance to the hospital is depending on the supplier; disregarded in the analysis.

Fig. 2. Decision point analysis for the procurement of stents.

3.5. Future state value stream mapping 4. Discussion

Creation of the future state VSM disclosed a progressive elimi-
nation of waste by using a consignment stock, which is completely
operated by the supplier. The future state VSM applies a pull inven-
tory control system (in contrast to the previous system depicted in
Fig. 2) to trigger the movement of a unit after withdrawal, which in
Toyota Production System terminology is referred to as ‘Kanban’1
(Fig. 3).
1
Japanese: “kan” ( ) means visual, and “ban” ( ) means card or
board; inventory control that historically uses cards to signal the need for an item.
However, other devices such as plastic markers (Kanban squares) or balls (often
golf balls) or an empty part-transport trolley are also commonly used to trigger the
movement, production, or supply of the unit.
One important factor in gaining control over an organization
is to know and profoundly understand its basic processes. Faulty
systems and processes, which may also induce medical errors, are
certainly one of the reasons for rising health care costs [8–10].
Industrial engineering practices and economic work organization
improvement techniques are increasingly applied in medical set-
tings in general [11] as well as in Radiology [12]. Especially the
Toyota Production System is frequently applied in optimizing
workflow in medical institutions [13–19]. This includes VSM tech-
niques in Radiology [20] as well as in daily trauma care [21], nursing
[22], emergency departments [23] or practices [24]. Computer
assisted control mechanisms such as radio frequency identifica-
tion device (RFID) technology [25] have been proven helpful in
industry, especially in logistics and transportation, and are increas-
ingly implemented in the healthcare sector as well. Also, electronic
 U.K. Teichgräber, M. de Bucourt / European Journal of Radiology 81 (2012) e47–e52
Fig. 3. Future state value stream map for the procurement of stents.
medical record usage increasingly assists in organizing efficient and
smooth processes [26].
4.1. Waste reduction
The elimination of waste is the main goal of VSM. Waste is often
not apparent. The term activity is often confused with value-added
work. For example, support functions such as inventory control
may generally not be considered wasteful. However, inventory con-
trol does not convert materials into customer’s products. In the
given context it does not implant the stent into the patients’ vessels.
According to VSM inventory control itself is not value-adding, fur-
thermore invisible to the patient, and therefore waste. Taking the
customer’s perspective is key to identifying waste. It is important to
distinguish value-adding and non-value-adding wastes from useful
efforts. There are many activities, which create confusion or debate
about their value-adding status: among others for example inspec-
tion, transportation, and administrative and support activities:
• Inspection never adds real value. It would be unnecessary if the
processes were executed correctly in the first place. It is also very
questionable if patients as customers would pay for it. If there is a
willingness to pay for a certain waste, it may be considered value-
adding for operational purposes. Otherwise inspection should be
considered a NVA process in TPS terminology.
• Transportation of patients and supplies within a hospital is an
example of NVA waste in TPS terminology. It is necessary for
patients because treatments have to take place in specialized
operating rooms or angio-suites. However, it may be possible to at
least partially reduce such waste with an improved spatial design
or centralization for certain services. But in-house transporta-
tion of supplies (stents) from central storage to the angio-suite is
unnecessary NVA waste as the supplier could straightforwardly
deliver the stent to the angiography suite.
• Interestingly administrative services are considered NAV waste
in TPS terminology because they do not interact directly with the
product. This includes scheduling of patients, human resource
managements and accounting. While these activities may be
necessary for a variety of internal and external reasons, they
still remain invisible to the patient and are therefore considered
waste.
e51
In general, the removal of unnecessary NVA waste is best done
using a continuous improvement approach (“change for the better”
– “Kaizen”), whereas the removal of necessary NVA waste requires
a more revolutionary strategy wherein the application of business
process re-engineering may be more appropriate.
4.2. VSM
While a VSM communicates valuable information, the most
important benefit comes from its creation. During the mapping
process insights grow, paradigms shift and consensus builds. Not
only does mapping lead to better processes, but also leads to a
consensus that enables and enhances implementation. VSM can
relentlessly disclose how a current process actually works and per-
forms. This knowledge can be used to develop economically more
efficient future VSM.
4.3. Limitations – waste removal inside value streams and
hospitals
Especially in a hospital environment the value stream focus
should cover the complete set of intra- and intercompany processes
of a service, including conception of requirement, product supply
and the patient’s receipt of services. A holistic approach may bet-
ter tackle the variety of complex, multifaceted problems plaguing
current healthcare systems [27]. There is a need to extend waste
removal of a certain process inside one or few institutions to a
complete supply chain. However, in a hospital environment one
may encounter difficulties doing this. These include lack of visibil-
ity along the value stream and lack of the tools appropriate to create
this visibility.
The waste terminology has been drawn from a manufacturing
environment. Therefore it is important not only to translate the
terminology but also to adopt it to a hospital environment.
Two recent studies assessing the success validity of implemen-
tation strategies like Six Sigma and Lean management tools in
health care industry state that there do exist gaps in the Six Sigma
and Lean health care quality improvement literature; they also
attested only weak evidence for actually measureable health care
quality improvement [28,29]. However, top-down ‘TPS-like’ sys-
tems may be more effective in health care organizations, compared
e52 U.K. Teichgräber, M. de Bucourt / European Journal of Radiology 81 (2012) e47–e52
to bottom-up “positive-deviance-like” approaches [30]. Many com-
panies in industry as well as in health care have tried to copy
Toyota’s famous production system without success; according to
Spear part of the reason may be that imitators fail to recognize the
underlying principles of TPS, focusing on specific tools and practices
instead [31].
Conflict of interest
There are no conflicts of interest to declare for this study. It was
not financed by third-party funds.
References
[1] Fischman D. Applying lean six sigma methodologies to improve efficiency time-
liness of care, and quality of care in an internal medicine residency clinic. Qual
Manage Health Care 2010;19:201–10.
[2] Furman C, Caplan R. Applying the Toyota Production System: using a patient
safety alert system to reduce error. Jt Comm J Qual Patient Saf 2007;33:376–86.
[3] Grove AL, Meredith JO, Macintyre M, Angelis J, Neailey K. Lean implementation
in primary care health visiting services in National Health Service UK. Qual Saf
Health Care 2010:28.
[4] Siebert JR. Increasing the efficiency of autopsy reporting. Arch Pathol Lab Med
2009;133:1932–7.
[5] Serrano L, Hegge P, Sato B, Richmond B, Stahnke L. Using LEAN principles
to improve quality, patient safety, and workflow in histology and anatomic
pathology. Adv Anat Pathol 2010;17:215–21.
[6] Jimmerson C, Weber D, Sobek DK. Reducing waste and errors: piloting lean prin-
ciples at Intermountain Healthcare. Jt Comm J Qual Patient Saf 2005;31:249–57.
[7] Rath F. Tools for developing a quality management program: proactive tools
(process mapping, value stream mapping, fault tree analysis, and failure mode
and effects analysis). Int J Radiat Oncol Biol Phys 2008;71(1 Suppl.):187–90.
[8] Spear SJ. Fixing health care from the inside, today. Harv Bus Rev 2005;83:78–91.
[9] Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce
medical errors in health care? Qual Manage Health Care 2007;16:226–38.
[10] Weinstock D. Lean healthcare. J Med Pract Manage 2008;23:339–41.
[11] Bertholey F, Bourniquel P, Rivery E, Coudurier N, Follea G. Work organisation
improvement methods applied to activities of Blood Transfusion Establish-
ments (BTE): Lean manufacturing, VSM, 5S. Transfus Clin Biol 2009;16:93–100.
[12] Rosen L. Applying industrial engineering practices to radiology. Radiol Manage
2004;26:32–5.
[13] Brown T, Duthe R. Getting ‘Lean’: hardwiring process excellence into Northeast
Health. J Healthcare Inf Manage 2009;23:34–8.
[14] Burkitt KH, Mor MK, Jain R, Kruszewski MS, McCray EE, Moreland ME. Toy-
ota production system quality improvement initiative improves perioperative
antibiotic therapy. Am J Manage Care 2009;15:633–42.
[15] Casey JT, Brinton TS, Gonzalez CM. Utilization of lean management principles
in the ambulatory clinic setting. Nat Clin Pract Urol 2009;6:146–53.
[16] Melanson SE, Goonan EM, Lobo MM, Baum JM, Paredes JD, Santos KS. Apply-
ing Lean/Toyota production system principles to improve phlebotomy patient
satisfaction and workflow. Am J Clin Pathol 2009;132:914–9.
[17] Young JQ, Wachter RM. Applying Toyota Production System principles to a
psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual
Patient Saf 2009;35:439–48.
[18] Stapleton FB, Hendricks J, Hagan P, DelBeccaro M. Modifying the Toyota Pro-
duction System for continuous performance improvement in an academic
children’s hospital. Pediatr Clin North Am 2009;56:799–813.
[19] Rutledge J, Xu M, Simpson J. Application of the Toyota Production System
improves core laboratory operations. Am J Clin Pathol 2010;133:24–31.
[20] Aakre KT, Valley TB, O’Connor MK. Quality initiatives: improving patient flow
for a bone densitometry practice: results from a Mayo Clinic radiology quality
initiative. Radiographics 2010;30:309–15.
[21] Barnes SL, Robinson BR, Richards JT, Zimmerman CE, Pritts TA, Tsuei BJ. The
devil is in the details: maximizing revenue for daily trauma care. Surgery
2008;144:670–5.
[22] Braaten JS, Bellhouse DE. Improving patient care by making small sustain-
able changes: a cardiac telemetry unit’s experience. Nurs Econ 2007;25:
162–6.
[23] Ng D, Vail G, Thomas S, Schmidt N. Applying the Lean principles of the Toyota
Production System to reduce wait times in the emergency department. CJEM
2010;12:50–7.
[24] Rizzo AA, Dommert HJ. Value stream mapping: a case study of one practice’s
experience. Del Med J 2009;81:187–8.
[25] Kumar S, Livermont G, McKewan G. Stage implementation of RFID in hospitals.
Technol Health Care 2010;18:31–46.
[26] Lin A, Harris M, Zalis M. Initial observations of electronic medical record usage
during CT and MRI interpretation: frequency of use and impact on workflow.
AJR Am J Roentgenol 2010;195:188–93.
[27] Fidsa GZ. Designing the future of healthcare. Stud Health Technol Inf
2009:14949–57.
[28] Vest JR, Gamm LD. A critical review of the research literature on Six SigmaLean
and StuderGroup’s Hardwiring Excellence in the United States: the need to
demonstrate and communicate the effectiveness of transformation strategies
in healthcare. Implement Sci 2009:435.
[29] Dellifraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of six sigma
and lean in the health care industry. Qual Manage Health Care 2010;19:
211–25.
[30] Rangachari P. Knowledge sharing and organizational learning in the context of
hospital infection prevention. Qual Manage Health Care 2010;19:34–46.
[31] Spear SJ. Learning to lead at Toyota. Harv Bus Rev 2004;82:78–86.