Total Quality Management

Vol. 17, No. 8, 1063 –1075, October 2006

Improving Quality through Value

Stream Mapping: A Case Study
of a Physician’s Clinic

RHONDA R. LUMMUS, ROBERT J. VOKURKA &

BRAD RODEGHIERO†

Iowa State University, Ames, USA;   Texas A&M University – Corpus Christi, Texas, USA;
†
Goodrich Corporation, Turbine Fuel Technologies, Greenville, South Carolina, USA

ABSTRACT As organizations look to improve overall systems to reduce costs and improve
throughput, lean principles are being more widely implemented. These lean initiatives began in
manufacturing, but have spread through other parts of the economy, including health care. This
paper reports on a value stream mapping project in a small medical clinic that resulted in
recommendations that would significantly lower patient wait time and increase patient
throughput. The new system can increase the capacity of the office without adding people or
equipment, lower waiting times for people with scheduled appointments, increase the opportunity
for patients without appointments to be seen at the last minute, and lower the stress levels for the
clinic’s staff.

KEY WORDS : Value stream mapping, lean processes, health care

Introduction
The need to provide customers with more value and at the same time reduce waste is a
constant for any firm or organization. Those concepts form the basis for what is known
as lean thinking. Lean thinking is focused on creating a perfect process of value creation
in product development and operations; along with the supporting processes within
organizations. Based on the Toyota Production System, Womack and Jones identified
five principles of lean thinking (Womack, 2002):

. Value is specified by the customer.

. Value streams that produce each product can be identified and wasted steps challenged.
. Product should continuously flow through value-creating steps.

Correspondence Address: Rhonda R. Lummus, College of Business, Iowa State University, 330 Carver Hall,
Ames, IA 50011-2063, USA. Email: rlummus@iastate.edu

1478-3363 Print=1478-3371 Online=06=081063–13 # 2006 Taylor & Francis

DOI: 10.1080=14783360600748091
1064 R. R. Lummus et al.

. Product should be pulled through steps where flow isn’t possible.

. Processes should be managed towards perfection to continuously reduce the time
needed to serve the customer.

Implementing lean thinking often includes value stream mapping; a process for linking
together lean and quality improvement initiatives in order to give the greatest overall
benefit to an organization (Tapping & Shuker, 2002). In early quality initiatives, compa-
nies implemented programs to increase their overall competitiveness; however, improve-
ments tended to be fairly localized. As these programs matured, quality initiatives moved
from stressing the importance of quality and increasing inspection, to identifying root
causes and solving problems upstream. Lean initiatives began to be used to reduce inven-
tory and processing time.
While companies reported great savings with these initiatives (e.g. General Electric
with hundreds of millions of dollars in savings through Six Sigma), questions arose as
to whether the reported savings were really making an impact on a company’s bottom
line. As this was analyzed, many realized that the vast numbers of localized improvements
were a benefit, but perhaps the impacts weren’t as great they potentially could be. Optimiz-
ing a sub process to increase the speed through that area does little to benefit the entire
system if that process wasn’t the bottleneck in the first place. It could even be a detriment
to the system if resources (e.g. human and equipment) were allocated to a project and
unknowingly taken away from a more deserving area. An example of this is a large expen-
diture on automated equipment with a very fast processing time. When using a cost
accounting method of allocating costs to that process, the costs drop significantly as the
processing times are reduced. However, the hidden costs may not be taken into account
as the cost of capital allocated to that process is not included. More often, the cost of
an increased in-process inventory is ignored. With an unbalanced processing time, man-
agers tend to push to keep the new equipment running. To do this a buffer of inventory
is required in front of the machine; and the fast processing time naturally creates a
stockpile before the next process.
As companies began to examine these situations, the need for a systematic way to link
these programs was obvious and, as a result, value stream mapping was born. Value stream
mapping gathers the tools and methodology to look at an entire process – including back
office support – and identify which areas, if improved, would offer the most benefit to the
entire system.
The manufacturing sector has led the way in implementing these improvements, but
many other areas of the economy are also beginning to utilize these tools. The healthcare
industry is one such sector. With financial pressures facing all sides of their business, hos-
pitals and offices around the country are striving for ways to cut costs and improve efficien-
cies. Examples have been reported from several health care facilities that have used the
tools in value stream mapping to improve patient care and financial results.

Lean Principles in Health Care

One example of the use of lean principles in the health care industry is at the Community
Medical Clinic in Missoula, Montana (Merriam, 2003). A frustrated orthopedic surgeon
worked with a nurse to find out if they could increase the number of patients served in
a day. They observed the process and found that the bottleneck was not in the operating
 Improving Quality through Value Stream Mapping 1065

room, but rather in the recovery area where it took 90 minutes to move a patient out so
another could be moved in from surgery. Basic observations were made and ideas were
easily implemented, which reduced the recovery cycle time to 60 minutes. This translated
to a capability to serve five patients per day from the previous four patients. The result was
a 25% increase in capacity without additional capital or hospital staff. Patients in the
community were able to be served much earlier than the six week wait for surgeries
prior to the changes.
Flinders Medical Centre in Adelaide, Australia has also used lean principles to reduce
emergency room waiting times (Roberts, 2004). This public hospital serves over 50,000
patients a year with 80% being served through the emergency services department. The
backlog created in the department was so poor that the hospital’s metrics actually
measured waiting times in the number of patients who had to wait more than four hours
and more than eight hours. Not surprisingly, waiting times of these lengths created signi-
ficant stress on staff and patients. Changes made over a five month period increased the
percentage of patients having to wait less than four hours from 20% to 65%, with an
internal goal of 90% in the following six months.
Progressive Healthcare, a multi-specialty group medical practice with more than 1,600
employees at multiple locations, is another example of a medical practice implementing
lean principles (Bushell et al., 2002). The scope of the value stream Progressive wanted
to work on is from the time a patient requests an appointment for primary care, until
they come in for the care and leave the facility. They looked at eliminating waste and
evaluating processes by thinking about what adds value from a patient point of view.
Through lean training the staff were able to standardize operations, organize the workplace
and improve work flow.
Allegheny General Hospital in Pittsburgh is among hospitals applying Toyota produc-
tion techniques; in their case to an intensive care unit (ICU) (Anonymous, 2004). Similar
to Toyota Motor Company’s policy of allowing any worker who spots a serious problem to
pull a cord and stop the assembly line, any ICU staffer can go to the chair of another
department if he or she thinks there is a problem that should be resolved. Their policy
according to Dr Richard Shannon, Allegheny General’s chair of medicine, is that no
problem should be left unsolved.
Wysocki (2004) describes how Toyota’s production techniques can be applied to
hospitals:

. Flow: In a factory, the Toyota approach emphasizes the smooth flow of people, gear and
finished goods. In hospitals, it emphasizes rapid flow of patients, staff.
. Root-Cause Analysis: In a factory or hospital, errors are examined immediately, and
countermeasures taken to avoid a repetition.
. Value Stream Mapping: Workers diagram work processes, aiming to eliminate steps
that aren’t valuable to customers (patients).
. Kaizen: This Japanese term for continuous improvement involves constant small steps
to improve efficiency.

From this background on other attempts to apply lean principles to medical services, it is
appropriate to evaluate applying lean principles, especially process mapping, to smaller
medical clinics. The medical office that is the subject of this paper is typical of small
city medical facilities. The employees face the same pressures of other larger city
1066 R. R. Lummus et al.

facilities, and while very knowledgeable about their field, have struggled with implement-
ing plans to improve performance of their facility.

Physician Clinic Situation

The medical clinic mapped in this study is located in a small city of about 15,000 people
located in the Midwestern part of the United States. As the city is the largest population
center in the area, the clinic draws from the population in the surrounding towns and
rural areas, which adds an additional 15,000 to the total served population base. As the
clinic is the only medical practice in the town, the doctors are also required to cover
the emergency room at the hospital (located next door). There are currently 12 doctors
in the practice (with three more expected to be hired), and they are a mix of Obste-
trics/Gynecology (OB), Family Practice, and Internal Medicine. The OB doctors work
in a semi-separated area of the clinic and their practice was not included in this study.
In general, the remaining doctors do not specifically specialize and all are capable of treat-
ing roughly the same set of medical problems.
The desire to improve the operations of the facility was prevalent throughout the
organization. This willingness to look at change was brought on by many of the same
internal and external pressures that the manufacturing world has faced for the last few
decades. These include financial pressures (both on the revenue and the cost side),
strain on the staff – especially the doctors, and a genuine desire to improve the service
level to their customers.
The financial pressures faced by the practice were two-fold. First, on the revenue side,
Medicare and large insurance companies have been putting downward pressure on
reimbursement amounts for several years. Just as most manufacturers are no longer able
to pass cost increases on to their customers through higher prices, the clinic was forced
to negotiate with large insurance carriers who refused to let the clinic set their own
prices. For Medicare reimbursements, the state in which the clinic is located has some
of the lowest reimbursement rates in the nation. And because it is the only clinic in the
area, they did not have the ability to refuse unprofitable patients. The clinic also is
facing challenges on the cost side of the business. The need for new equipment, rising
insurance rates, and normal inflationary pressures without the ability to raise prices,
were quickly eating into the margins. As it is a small clinic, it has not been able to reap
any economy of scale benefits. For these reasons, the practice is in the middle of nego-
tiations to sell to a large medical service provider.
The personal strain on the clinic staff (primarily the doctors) was also a major concern.
Making sometimes unpleasant medical decisions is stressful enough, but the constant ebb
and flow of the work load – generally running late at the end of the day – added additional
stress to the employees. Located in a primarily rural area, the clinic also faced difficulties
in recruiting additional staff. Consistently feeling short staffed and overworked became a
self-fulfilling cycle as doctors would sometimes leave the practice for this reason –
making it worse on the remaining staff.
Nearly every person at the clinic – from the doctors to the administrators to the nurses
to the clerks - expressed a sincere desire to serve its customer base better. It was recog-
nized that they needed to put limits on the available services, but also never wanted to
turn away, or put off, a patient in need. Patients with obvious critical medical needs are
always accommodated. However, a large number of patients who are ill and
 Improving Quality through Value Stream Mapping 1067

uncomfortable sometimes have to wait one to two days to be treated. These situations
frustrate the entire staff, who typically joined the medical field out of a sincere desire to
help people feel better.

Mapping the Present State

The first hurdle to overcome when mapping the present state was the authors’ lack of
knowledge of the medical industry. Walking into the office, there was little conception
of what the processes were or where there may be improvement opportunities. There
was an early recognition that the medical office was basically the same as any manu-
facturing facility. It boiled down to a value-added process that the customers desire and
are willing to pay for along with many other processes that support these. All of the
staff (from the doctors, administrators, nurses and clerks) had their own ideas of
‘what’s wrong with this place’, but in general were all very helpful.
The mapping project concentrated on the patient flow through the system and it soon
became apparent this was the largest issue in the clinic. Casual conversation with two
doctors over coffee early in the morning indicated that they felt that the staff in the sche-
duling department was woefully inadequate. They were unhappy with the way their patient
load seemed to be all or nothing. Early in the day the workload was often slow, especially
if there was a no-show appointment. Then late in the day they often felt as if they were
constantly backed-up and they would get home late for dinner. Later in the morning a
meeting with the administrator and head nurse revealed that they had a slightly different
take on the situation. Their opinion was that ‘yes, it’s true the scheduling department left a
lot to be desired. But what did the doctors expect when you have $10/hour staff making
decisions ahead of time on how long a doctor would need to spend with a patient?’ An
attempt had been made to improve the accuracy of this process by creating a list of symp-
toms and the associated time to serve that patient. Unfortunately this did little to improve
the scheduling accuracy as the symptoms were very vague and patients were reluctant to
share real information with the telephone operator.
After setting our expectations low for the staff we would meet in the scheduling depart-
ment, we were pleasantly surprised that they appeared very competent. Not only were
they adept at handling the expensive computer system used to schedule the doctor’s appoint-
ments, they knew the personality quirks of the different doctors and how that would affect
the likely time required with the patient. They also had a better appreciation of the severity
and time required to process different medical conditions than we would have expected.
The staff at the office had tried to implement various plans to improve the planning and
patient flow through the system. The first thing tried was to provide better templates to the
scheduling staff as to how long it would take a doctor to process a patient with a given list
of symptoms. Very detailed charts were made that split out the type of physician and listed
symptoms correlated to anticipated appointment times and other rules of thumb. Unfortu-
nately, this did little to improve the real situation. Patients were generally adverse to
discussing real problems with the scheduling office and the variation in the way different
doctors handled and treated patients made generalities impractical.
The clinic had also experimented with a smaller women’s clinic split off from the main
office. This area was not included in the mapping process, but many people pointed to it as
something they believed would work better in the main office. In this area, one scheduler
sat in the nurse’s area and served two doctors. Few of the problems observed in the front
1068 R. R. Lummus et al.

office occurred here, causing others to feel that this was the best practice. In reality, the
reason it worked better was probably a combination of several special characteristics.
First, feedback was generated due to the physical proximity to the process (impractical
for the larger clinic). Second, the women’s clinic tended to have more repeat patients
and symptoms (e.g. pregnant women) where it was easier to plan for the time due to pre-
vious knowledge of the patient and the problem. All of these issues made it obvious that
mapping and hopefully improving the way patients were scheduled and flowed through the
system would have the biggest impact upon the facility.
Not fully understanding the processes involved in moving patients through the office,
we began with the time the patient spent with the doctor and worked up and downstream
from there. We began here because it seemed that this is where the value-added steps took
place. It turned out that a lot of time had already been spent evaluating how long it takes a
doctor to process a patient (probably because this was the only process that generates
revenue). The staff was confident that the average takt time to process a patient was
15 minutes. Digging deeper into the process revealed that this process variability meant
that the actual time with a patient would take anywhere from five to 45 minutes, dependent
upon a number of variables. After the initial time spent with the doctor, further lab work
may be required. The doctor would then order the labs and send the patient to that process.
If it was a quick test, the patient would then go back to the doctor for immediate follow-up
and processing. If the test results would take a longer time to process, then the patient
would schedule a follow-up appointment and go home.
Wanting to know how the patient arrived in the actual examination room to be pro-
cessed by the doctor, we went back to the beginning and spoke with the scheduling
staff and walked through the process. When a patient called in, the staff would process
his/her request using a seemingly endless set of rules for the specific doctor, the length
of time to schedule, when to schedule, etc. They would then input the appointment into
the computer system. At the scheduled appointment time, the patient would arrive at
the office and wait in line to check in with the receptionist. At this time the receptionist
would indicate in the computer system that the patient had arrived. This would prompt
the staff in the medical chart area to pull the patient’s chart and take it to the appropriate
office. The nurse’s desk in the doctor’s area would also receive notification via the
computer system that the patient had arrived. The patient would then wait until
the nurse called them to the examination room. This would typically occur in order of
scheduled appointment time.
Once the patient was in the examination room the nurse would take preliminary data.
This average takt time was five minutes, with little variation. The process typically took
no less than three minutes and no more than eight. Once processed by the nurse, the
doctor would take the patient in a FIFO method as sent by the nurse. A map of the
current state can be seen in Figure 1.

Observations on the Current State

After mapping the current state, it became apparent why there are process flow problems
within the office. The patients are pushed through the system by a scheduling department
far upstream in the process who schedule several days in advance with no immediate feed-
back to the situation in the offices. The large variation in time the patients spend being
processed by the doctor also creates havoc on the system. The fact that the maximum
 Improving Quality through Value Stream Mapping 1069

Figure 1. Map of Current State

variation time over the average is significant makes it nearly impossible to make up the
backlog created by a severe overage. All of this occurs with no immediate feedback to
scheduling or reception. The patients just keep being pushed into the system according
to a schedule set days in advance. Patients are caught in the system with no chance of
getting out of the lane they are in. The problem can be made even worse if the doctor
is on emergency room call and has to leave for any amount of time. Only in very
severe situations were the patients told the wait would be excessively long, and then
their only option is to reschedule. The service industry is also unlike manufacturing in
that the in-process inventories must be emptied every day before the staff can leave (as
the inventory is people, not manufactured parts).

Suggested Future State

After observing the present state and analyzing the problems, our first reaction was to
propose the implementation of a pull system to replace the existing push system.
However, the differences in the demands of the health care industry versus a typical
manufacturing environment must be recognized. While most of the doctors in the clinic
are capable of addressing the same medical needs, many times a continued relationship
between the doctor and patient is medically desirable. Using the large number of available
doctors to smooth out backlogs created by large process variations is advantageous
from a flow standpoint; however it can result it sacrifices on the quality of care if not
done correctly.
The following section describes a list of issues that were used in the proposed future
state in this paper. A more exhaustive list with data gathered to support assumptions
1070 R. R. Lummus et al.

would need to be made prior to actually implementing any plan. Roughly 50% of the
patients serviced are either ongoing or follow-up cases that need to be served by a specific
physician. The other 50% are walk-up cases such as those with the flu or other minor
illness that could realistically be treated by any available physician. It is assumed that
most patients with these minor cases would be willing to see any physician in exchange
for quicker access and less waiting time in the office. People are willing to wait longer
and will accept pre-scheduled appointments moving ahead of them in line if they have
called at the last minute to see a physician and have been accommodated.
The following list summarizes issues that must be considered in the new system:

1. A ‘pass-through’ lane must be available to handle acute cases that arrive, without
adding significant work-around steps to the support staff.
2. The physician’s time is similar to a hotel room or airline seat – once it has passed
without creating revenue – that potential revenue is lost.
3. All in-process inventories must be processed by the end of the day.
4. The time with the physician is by far the bottleneck in the system, while the average
time of a 15 minute cycle is viewed as highly accurate.

System Description
The proposed system begins with segregating the patients to be serviced into three groups.
The first are acute, or near emergency cases, which arrive at the clinic instead of the emer-
gency room at the hospital. These patients account for a very small percentage of the
patients served, but must be seen immediately. The other two groups of patients are
those that make a pre-scheduled appointment and those that are last minute walk-in
patients. The clinic would need to analyze historical data to determine the distribution
of cases that fall into each category, but a good starting point is to estimate that the patients
with appointments and walk-ins are roughly equal, or each about 50% of the cases.
For the pre-scheduled appointments, the time slots available to fill for each doctor
should be limited to no more than 50% of each available day. With a 15-minute
average cycle time that means an appointment could be scheduled every 30 minutes.
These appointments should also be scheduled somewhat evenly across the day. This
spacing will benefit the system because although these patients are still being ‘pushed’
into the system, it is at a cycle time rate variation that would not be disruptive because
of the built in capacity limit. When the patients with appointments arrive, they have
priority over any walk-in patients waiting to be served.
A system is also needed to monitor the number of walk-in patients arriving at any one
time. In this study, the term ‘walk-in’ is defined as those patients who call the day prior, or
the day of, and request to be seen by a doctor. The system’s capacity and backlog needs to
be monitored and time frames given to the patient based on when the system will have the
available capacity to serve them.
When the patient arrives at either the pre-scheduled appointment time or the given
‘walk-up’ time, they would report to the reception area. If they have a pre-scheduled
appointment time, they would be sent directly to the waiting area of the appropriate
doctor. If they have a walk-up timeslot, the receptionist would determine which doctor
is next available and direct the patient to that area, also notifying the appropriate nurse
 Improving Quality through Value Stream Mapping 1071

and chart area that the patient has been directed to them. At the nurses’ desk, there would
be four FIFO lanes. These include:

1. Acute patients who require immediate care

2. Patients who have been seen once by a physician and have had labs ordered and only
need a quick follow-up visit with the doctor
3. Pre-scheduled appointments
4. Walk-up patients

Based on these priorities, the nurse would take the next patient, and always empty lane 1 first.
If lane 1 is empty they will look at lane 2. If that is empty then lane 3, and finally lane 4.
While on the surface it appears that the patients in lane 4 may end up waiting excessive
amounts of time, this has been addressed by limiting the number of patients that can be
put into lanes 1 to 3 compared to the overall capacity of the system. If the system does
begin to become backlogged because of long process times, the nurse is responsible for
notifying the reception area that no more walk-in patients should be directed to that
physician. See Figure 2 for a proposed future state.

Figure 2. Map of Proposed Future State

1072 R. R. Lummus et al.

Scheduling Board
One of the key aspects of the proposed pull system is the proper use of a scheduling plan to
keep a steady flow of patients in the door. Since the clinic deals with people and not hard-
ware, the acceptable amount of WIP in queue cannot be calculated financially, but rather
by an amount of time judged to be acceptable for busy people to wait prior to seeing a
physician.
The proposed scheduling board begins by plotting the total estimated capacity of the
clinic, and moving backwards as time slots become committed. See Table 1 for an
example of a scheduling chart. Initially the timeslots when certain physicians are unavail-
able would be eliminated from consideration. This could occur for several reasons,
e.g. vacation, administrative duties, etc. But it could also be used as a buffer against
planned capacity for unplanned events. Because of the small size of the town, one
doctor per day is required to handle emergency calls at the emergency room in the adjoin-
ing hospital. If on average, this commitment requires one-half of the doctor’s time on a
particular day then one-half of the timeslots can be eliminated from that physician’s
board. This significantly reduces the risk of over committing any doctor’s time.
Lastly, the schedulers would give out timeframes to last minute patients per available
timeslots on the board. They would fill up the early timeslots first, while steadily filling
in those later in the day, trying to keep a downward sloping capacity fill level. There
are multiple reasons for filling the capacity this way. The first is that like hotel rooms
or airline seats, once a timeslot has passed without a patient, that revenue is forever lost
to the clinic. So filling timeslots early gives the clinic the opportunity to have open
capacity if another patient were to call later. The reduced level of planned work later in
the day also allows the clinic a chance to catch-up when statistics catch up and a dispro-
portionate number of patients run to the high side of the process time. The schedulers
would be told during the day to slow down the inflow of patients, allowing the system
to catch-up. Finally, having the day slow down at the end would lower the stress levels
on the staff as they were able to see the same number or more patients, while on
average being able to leave earlier in the evening.

Benefits and Challenges of the Proposed System

This paper has offered a proposed future state for a small medical clinic, based on lean
mapping principles. The authors identified several challenges to implementation. The
first would be to define the types of cases that need to be pre-scheduled with a specific
physician versus those that could be seen by any available doctor. These definitions
would then need to be communicated to the scheduling department who would have to
schedule appointments accordingly. In addition, the patient base needs to be familiarized
with the new system. This may not be an easy task because currently most patients call for
a specific appointment time. Many people may also be reluctant to see any doctor besides
their regular physician for even the most minor problem. The details of the system would
need to be set up to discourage inflexible behavior by patients and reward cooperation by
moving people ahead or behind in the line accordingly.
On the plus side, the new system has the potential to increase the capacity of the office
without adding people or equipment, lower waiting times for people with scheduled
appointments, increase the opportunity for patients to be seen at the last minute when
 Table 1. Scheduling Board Example

Doctor 9:00 9:15 9:30 9:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45 1:00 1:15 1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00

Improving Quality through Value Stream Mapping

1 S F F F S S S S S
2 F F S F F F S F S F S S S
3 S F F F S F S F F F S F S S S S
4 F F F S F F F F S F S F S F F S S S
5 S F F F S F F S F F F F S F S F F S S S S
6 S F F F S F F F F S F F S F F F S F F F S S
7 X X X X X X X X X X X X X X X X X X X X X X X X X
8 F S F F S F F F S F S F F F S F S F F S F F S
9 S F F F F F S F F F F F F F F S F F S F F F F F S
10 X F X F X F X F X F X F X F X F X F X F X F X F X

X Unavailable.
S Pre-Schedule Appt.
F Tentatively Filled Walk-Up.

1073
1074 R. R. Lummus et al.

they are ill, and lower the stress on the staff by making the end of the day less stressful. The
system will add capacity because the ability to use an open physician will eliminate the
need to schedule in the buffer time that the present state uses to try to compensate for
the variability in cycle time. Even though each doctor’s capacity may change day-to-
day depending on the specific case, the clinic’s overall capacity stays roughly constant
because of the large number of doctors. Knowing that if a doctor’s patients are queuing
up, patients are automatically re-routed to a physician with available capacity; this
allows the entire system to be scheduled with less buffer capacity. When a doctor gets a
string of appointments that take less than the average time, the open time can be filled
with walk-in appointments that off-load another doctor whose patients are facing long
wait times.
Patients with pre-scheduled appointments will also have shorter wait times because they
move to the front of the FIFO lanes. The chances of being caught in a statistical cycle of
several patients in front of them taking too much time and backlogging the system is also
reduced because the system is set-up to prevent more patients from being added to the
queue until the doctor can catch-up. Last minute patients are also better served because
the increased capacity and flexibility of the system means there is a better chance that a
physician will have time available on demand. Very sick patients will generally be able
to be treated very quickly when they most require fast treatment.
Finally, the leveling of the patients through the system will make the staff’s time more
predictable, especially in the evenings. The process variability of the current state was
naturally going to have dead time and backlogs. When the backlogs hit in the mornings,
sometimes a slow afternoon would allow them to catch up before evening. But if a backlog
hit in the afternoon, the possible slow time from that morning could not be retrieved.
This commonly led to late evenings as staff could not go home until the backlog was
cleared. Leveling the effects of the cycle variability by using the clinic’s other resources
immediately when a backlog begins to build in one area, will greatly alleviate the days
when staff in one area are required to work late into the evening to clear a specific
backlog. This reduction of stress could also have the trickle down effect of improving
patient care by reducing the staff’s stress levels.

Conclusions
The manufacturing sector has historically led in the implementation of lean principles.
Many other areas of the economy are also beginning to identify the benefits to utilizing
these tools. The healthcare industry is one such sector. Financial pressures are forcing
hospitals and medical offices around the country to look for ways to cut costs and
improve efficiencies.
This case study of a small medical clinic located in the Midwestern United States is an
example of applying lean principles to medical services. The medical office is typical of
small city medical facilities that are very knowledgeable about the medical profession, but
have struggled to implement plans to improve the performance of their facility.
Working in conjunction with the clinic staff, the authors conducted a mapping of the
current state of patient flow through the clinic. The focus was to look at what added
value from the customer standpoint; in this case the customer is the patient. From the
map of the current state, a proposed future state was presented to the clinic. The benefits
to the proposed state were outlined to the clinic staff. Currently the staff is considering how
 Improving Quality through Value Stream Mapping 1075

best to implement the new patient flow concepts. The greatest concern to staff is how to
educate patients to look at the overall benefits to a revised system. The process improve-
ments have been shown to improve the overall performance of the clinic, but the customer
must believe that it adds value to their particular service need from the clinic.

References
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