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:
[email protected] 1478-3363 Print=1478-3371 Online=06=081063–13 # 2006 Taylor & Francis DOI: 10.1080=14783360600748091
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. 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, companies implemented programs to increase their overall competitiveness; however, improvements 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 inventory 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. Optimizing 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 expenditure 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, managers 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, hospitals and offices around the country are striving for ways to cut costs and improve efficiencies. 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
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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 significant 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 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 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
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facilities, and while very knowledgeable about their field, have struggled with implementing 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 Obstetrics/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 treating 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 negotiations 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 recognized 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
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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 manufacturing 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 scheduling 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 symptoms 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 department, 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 appointments, 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. Unfortunately, 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
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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 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 processed 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 feedback 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
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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
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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 emergency 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
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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
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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 hardware, 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 unavailable 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 adjoining 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 disproportionate 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 S F S F S S X F S X
F F F F F F X S F F
F S F F F F X F F X
F F F S F F X F F F
X Unavailable. S Pre-Schedule Appt. F Tentatively Filled Walk-Up.
S F S F S S X S F X
F F F F F X F F F
S S F F F X F S X
F F F S F X F F F
S S F S F F X S F X
S F F F S X F F F
S S F F X S F X
F F F F F X F F F
S
S S S S S X F F X
F F F X F F F
S
S F S F X S F X
S S F F X F S F
S X F X
S
S F F X S F F
S F X F S X
S F X F F F
S S S S X S F X
S S X F F F
X F F X
X F F
S X S S X
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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-today 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
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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 improvements 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 Anonymous (2004) Hospitals adopt Toyota production techniques to cut costs, improve service in intensive care, Quality Progress, 37(6), pp. 15–16. Bushell, S. et al. (2002) Discovering lean thinking at progressive healthcare, The Journal for Quality and Participation, 25(2), pp. 20– 25. Merraim, G. (2004) Efficiency revs up healthcare, Missoulian.Com. February 29, http://www.missoulian.com/ articles/2004/02/29/news/local/news03.txt. Roberts, G. (2004) Hospital’s assembly 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; what Paul O’Neill’s been up to, Wall Street Journal, April 9, pp. A1.
