Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
An Application of Value Stream Mapping on Health Care
Facilities for Reducing Non Value Added Time
Khairun Nahar *, Md. Sazol Ahmmed, Faisal Arif and Mosharraf Hossain
Value Stream Mapping is a lean management tool to facilitate the
overall systems to eliminate waste and improve quality. This paper
reports on VSM which is applied to the hospital that results in
increasing throughput 21% and also reduces patient’s waiting time
effectively. However the literature review implies that performance
excellence can be achieved through Lean best practices. The VSM
tool is very practicable tool which will work at the lowest time but its
performance is up to the mark. In this study the propose system
increases the capacity of the hospital without adding people or
equipment, decreases the waiting time 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.
Field of Research: Management
1. Introduction
Value stream mapping is a lean management method for analyzing the current state
and designing a future state for the series of events that take a product or service from
its beginning through to the customer. It provides optimum value to the customer
through a complete value creation process with minimum waste in: design (concept to
customer), build (order to delivery) and sustain (in-use through life cycle to service.
Many organizations pursuing “lean” conversions have realized that improvement
events alone are not enough. Improvement events create localized improvements,
value stream mapping & analysis strengthens the gains by providing vision and plans
that connect all improvement activities. The medical hospital mapped in this study is
located in a small city Rajshahi of about 30,000 people located in the northern part of
Bangladesh. The hospital name is Barind Medical College & Hospital. This hospital is
one of the leading hospitals in Rajshahi division. It was established in 2010.It was
located in the premises of Padma Residential Area. The location of this area is very
beautiful. It is also very reputed medical college in the Rajshahi division. The campus
of this hospital is very beautiful and charming. The hospital building is a 5 stored
building along with the medical college. There is also a nice administrative office
alongside the hospital.
___________________________________________________________________
Prof. Dr. Md. Mosharraf Hossain, Department of Industrial & Production Engineering, Rajshahi
University of Engineering & Technology, Rajshahi-6204, Bangladesh.
*Corresponding Author: Khairun Nahar, Assistant Professor, Department of Industrial & Production
Engineering, Rajshahi University of Engineering & Technology, Rajshahi-6204, Bangladesh. Email:
shapla05.ipe@gmail.com
Md. Sazol Ahmmed, and Md. Faisal Arif, Department of Industrial & Production Engineering, Rajshahi
University of Engineering & Technology, Rajshahi-6204, Bangladesh.
The people also satisfy at the environment the health providing facilities, the other
valuable services which are provided by the doctors, nurses, staffs. The doctors who
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
are engaged, they are well qualified .They are also very helpful for rendering service
to the people. The administrative sections who conduct the hospital are well mannered
and dedicate to their work. Though the age of the hospital is not so long, therefore day
by day it is going to the peak of success. The hospital is not only rendering health care
facilities but also provide many other facilities such as lab facilities, dispensary shop
etc. Barind hospital has developed, advanced, and nourished lab facilities. There is a
lot of advanced equipment for examining various complicated diseases. To operate
the lab correctly and effectively there are a lot of qualified doctors, lab technologists
and other people who are good at this. Besides this there is also a facility of free health
providing facilities for the destitute people. This is one of the most important features
of this hospital. In this hospital there is also an opportunity of dispensary shop where
different kinds of national and international medicines are available.
As the city is the largest population center in the area, the hospital 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 hospital is the one of the medical practice
in the town, the doctors are also required to cover the emergency room at the hospital
(located next door). There are currently 20 doctors in the practice (with five more
expected to be hired), and they are a mix of Obstetrics/Gynecology (OB), Family
Practice, and Internal Medicine. The OB doctors work in a semi-separated area of the
hospital and their practice was not included in this study. In general, the remaining
doctors do not specifically specialize and all are capable of treating roughly the same
set of medical problems.
2. Literature Review
Use of lean principals in the health care industry is at the community, medical clinic in
Missoula Monatana (Merriam, 2003).An orthopedic surgeon worked with a nurse to
find out the bottle neck in the operating room and decrease patient flow time from 90
minutes to 60 minutes. The result was 25% increase in capacity without additional
capital or hospital staff. Medical center in Adelaide, Australia has also used lean
principles to reduce emergency room waiting time (Roberts, 2004).Fifty thousand
patients are served by the public hospital and 80% of them are served through the
emergency service department. Reducing the waiting time both the staffs and patients
are relieved from the stresses. They had changed the running situation and watched
very significant result about 20 -65 percentage reduction of waiting time. The scope of
the value stream progressive wanted to work on is from the time a patient 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. Allegheny General Hospital in Pittsburgh in among
hospitals applying Toyota production 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 serious problem to pull a cordand stop the assembly line, any ICU
staffer can go to the chair of another department if he or she thinks there is a problem
should be resolved. In 2009, the Health Foundation in the United Kingdom
commissioned the Institute for Healthcare Improvement (IHI) to design a tool to help
identify clinical waste within the hospital setting. The Health Foundation is an
independent charity that funds projects in the United Kingdom to improve healthcare
quality. The IHI is also an independent not-for-profit organization whose mission is to
improve healthcare worldwide through implementing the lean thinking.
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
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, companies implemented
programs to increase their overall competitiveness; however, improvements tended to
be fairly localized. From this background we apply lean principles in medical service
for process mapping and decrease waiting time. The medical office that is subject of
this paper is typical a small city medical facility where the employee face the same
pressures of the large city.
3. Methodology
3.1 Mapping the Present State
Patients were usually reluctant in 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 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
previous 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 7-8 minutes. But it varies according to patients casualty .Digging deeper
into the process revealed that this process variability meant that the actual time with a
patient would take anywhere from 10 to 20 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. 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 file book and
give them serial number. 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 send the patients after receiving the serial number. This would prompt the
staff in the medical chart area to pull the patient’s chart and take it to the appropriate
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
office. The nurse’s desk in the doctor’s area would also receive notification 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.
3.2 Statistics of the hospital
 Average number of general patients = 100-150.
 Average number of emergency patients = 20-30.
 Number of outdoor doctors = 20.
 Number of emergency doctors = 2.
 Outdoor doctors are available = 8:00 am to 2:30 pm.
 Emergency doctors are available = 2:30 pm to 8:00 am.
 Number of receptionist = 1.
 Number of person in ticket counter = 3.
 Microbiology and pathology department are available = 8:00 am to 2:30 pm.
After observing the statistics we come to the point that there are some problems which
are needed to work done. They are:
1. Emergency doctors are not available at 8:00 am to 2:30 pm. Some outdoor
doctors are working here to meet up the demand of the emergency doctor. But
for this reason there create some inventories.
2. Sample collection is a part of Pathology and Microbiology Department. But they
are divided into two categories which are non-value added non-essential items.
It will just increase waiting time.
3. Those who are engaged in flowing patients are not well trained. They have not
any knowledge about FIFO lane which is very essential in smoothing patient
flow.
4. The whole system follows the banal arrangement which creates a longer
processing time.
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
Figure 1 Current Value Stream Mapping
3.3 Suggested Future State
After observing the present state and analyzing the problems,. 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.
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
emergency room at the hospital. The other two groups of patients are those that make
a pre-scheduled appointment and those that are last minute walk-in patients. The
hospital 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 and chart area that the patient has
been directed to them. At the nurses’ desk, there would be four FIFO lanes.
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
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. Figure 2 is for a proposed future state
value stream mapping.
Figure 2 Proposed Value Stream Mapping
3.4 Comparison of CSM and FSM
The comparison between current state mapping and future state mapping is given
below-
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
Table 1 Comparison between current and future state mapping
Current state map
Future state map
Non value adding time
13.04 min
5.2 min
Value adding time
25.13 min
21.10 min
% of NVA/VA time
51.89%
24.64%
Increase throughput from
current state map
Average takt
-
21%
8 min
11 min
Standard deviation from takt
1.37 min
0.95 min
3.5 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. We identified several challenges for 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 .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
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.. 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 prescheduled appointments will also have shorter wait times because they move to the
front of the FIFO lanes. 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.
4. 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 medical hospital located in the Northern part
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
of Bangladesh 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, we conducted
a mapping of the current state of patient flow through the hospital. 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 hospital. The benefits to the proposed state were outlined to the clinic staff.
Proceedings of 13th Asian Business Research Conference
26 - 27 December, 2015, BIAM Foundation, Dhaka, Bangladesh,
ISBN: 978-1-922069-93-1
References:
Anonymous (2004), ‘hospitals adopt Toyota production techniques to cut cost,improve
services in intensive care’, quality progress, 37(6),pp.15-16.
Graban, Mark (2011), ‘Lean Hospitals: Improving Quality, Patient Safety, and
Employee Engagement’, Boca Raton, FL: CRC Press, ISBN 9781439870433.
Merraim, G. (2004), ‘Efficiency revs up healthcare’, Missoulian.com., February 29,
local, news 03.
Roberts, G. (2004), ‘Hospital’s assemblies cure all’, The Australian, April 29.
Tapping, D. and Shuker, T. (2002), ‘Value Stream Management: Eight Steps to
Planning, Mapping and Sustaining Lean Improvements’, New York: (productivity
press).
Womack, j. p. (2002), ‘Lean thinking: where have we been and where are we going?’
Manufacturing Engineering, 129 (3),pp. L2-L6.
Wysocki, B. (2004), ‘Industrial strength: to fix health care, hospitals take tips from
factory floor, adopting Toyota techniques can cut costs, wait times; ferreting out
an infection’, wall street journal, April 9.