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Public Access Author manuscript
Am J Gastroenterol. Author manuscript; available in PMC 2016 October 01.
Published in final edited form as:
Am J Gastroenterol. 2016 April ; 111(4): 447–448. doi:10.1038/ajg.2016.38.
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What Is Value Stream Mapping, and How Can It Help My

Practice?
Ziad F. Gellad, MD, MPH1,2 and Theodore Eugene Day, DSc3
1Durham VA Medical Center, Durham, North Carolina, USA
2Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina,
USA
3Office
of Safety and Medical Operations, The Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania, USA

Lean management is an organizational philosophy and accompanying set of tools that

originate from a study of business processes employed by the Toyota Motor Company in the
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1980s. More recently, a similar approach, termed Lean Healthcare, has been employed by an
increasing number of health-care systems (1). The goal of lean in health care is to improve
value from the patient's perspective (2). Value stream mapping is a key tool used in lean to
help define steps in a process that bring the organization or unit closer to this goal. In the
next sections, we will review value stream mapping in the context of lean, provide an
example of a value stream map (VSM) for a gastroenterology clinic, and suggest practical
steps a practice can take to employ this approach in everyday work.

A VSM is a visual representation of the flow of people, material, and information in a

complex system (3,4). By including material and information, the VSM differs from a
traditional process flow map; in fact, this method was originally called “Material and
Information Flow Mapping” at Toyota (5). The goal of creating such a detailed map is to
facilitate a common understanding of this flow, shared by all stakeholders, to enable process
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improvement through the elimination of non-value added steps. There are several key
features of a VSM that deserve mention. First, the VSM must be created by a
multidisciplinary team that includes front-line workers. One of the core tenets of lean is that
empowerment of front-line workers to lead improvement efforts creates a cultural
transformation in an organization toward one of continuous improvement. Furthermore,
front-line workers understand a particular process with a level of intimacy not available to
more senior managers. Second, a VSM must be detailed enough to allow identification of all
non-value added steps, no matter how small. The cumulative improvement from many small
changes is what makes lean so impactful. Third, for each step in the VSM, the team must

Correspondence: Ziad F. Gellad, MD, MPH, Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street,
Rm. 0311, Box 3850, Durham, North Carolina 27705, USA. ziad.gellad@duke.edu.
Guarantor of the article: Ziad F. Gellad, MD, MPH.
Specific author contributions: Ziad F. Gellad and Theodore Eugene Day contributed to manuscript design, manuscript drafting,
critical revision, and approval of the final draft.
Potential competing interests: None.
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consider whether the step brings value to the patient and whether a safer, more efficient, or
more effective option exists. If the answer to any of these questions is “yes”, then there is an
opportunity for improvement. Fourth, the creation of a VSM is an iterative process. As
interventions are undertaken to eliminate waste, the VSM changes and must be revaluated in
comparison with an “ideal” state. As such, it represents the continuous nature of lean.
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Several examples of VSM in gastroenterology are available in the literature (6–8). In each of
these examples, a detailed VSM created by a multidisciplinary team is utilized to identify
waste in a process and guide successful quality improvement interventions. The complexity
of each of these VSM differs, however, reflecting the process being modeled and the
resources available to assist in the improvement effort. Indeed, the assistance of experts in
lean can be invaluable in the early stages of a lean journey to model best practices.

As an example, Figure 1 shows a template for a simple VSM of an outpatient clinic. Patients
arrive, sign in, register, undergo intake, an exam, and are discharged. Between each of these
events is a waiting time for the next operation to proceed. For each event in the process, the
value added time of the patient interaction may be calculated, as well as the non-value added
time of the wait between each event. Non-value added time may be broken up into both
“necessary non-value added time” and “waste”. Necessary non-value added time may be, for
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example, insurance verification that must, for regulatory reasons, be processed by fax rather
than phone or electronically, resulting in delays that are beyond the control of the system.
Figure 1 shows both the process flow of the patient through the clinical environment, and the
necessary communication at each step with the electronic medical record and between
members of the medical team. This represents both the flow of material (people) and
information. Using this tool, it is possible to identify and isolate the effects of process
interventions to specific sub-stages, thereby revealing the inherent value of potential
operation improvements.

Value stream mapping is but one tool in the set of tools and principles of Lean Healthcare.
Although a detailed instruction manual is beyond the scope of this commentary, practices are
encouraged to use the principles highlighted above and the references provided to explore
the benefits that value stream mapping can bring to their practice.
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Acknowledgments
The authors thank Anna Frye, BS, of The Children's Hospital of Philadelphia for assistance with the figure.

Financial support: Gellad's effort is funded by Veterans Affairs Health Services Research and Development Career
Development Award (CDA 14-158).

References
1. Gabow, PA.; Goodman, PL. The lean prescription: powerful medicine for our ailing healthcare
system. CRC Press; Boca Raton, FL: 2015.
2. Toussaint JS, Berry LL. The promise of lean in health care. Mayo Clin Proc. 2013; 88:74–82.
[PubMed: 23274021]
3. Lee E, Grooms R, Mamidala S, et al. Six easy steps on how to create a lean sigma value stream map
for a multidisciplinary clinical operation. J Am Coll Radiol. 2014; 11:1144–9. [PubMed: 25467727]

Am J Gastroenterol. Author manuscript; available in PMC 2016 October 01.

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4. Simon RW, Canacari EG. A practiceal guide to applying lean tools and management principles to
health care improvement projects. AORN J. 2012; 95:85–100. [PubMed: 22201573]
5. Rother M, Shook J. Learning to see: value-stream mapping to create value and eliminate muda Lean
Enterprise Institute: Cambridge. MA. 1999
6. Sugianto JZ, Stewart B, Ambruzs JM, et al. Applying the principles of lean production to
gastrointestinal biopsy handling: from the factory floor to the anatomic pathology laboratory. Lab
Med. 2015; 46:259–64. [PubMed: 26199269]
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7. Patel KK, Cummings S, Sellin J, et al. Applying lean design principles to a gastrointestinal
endoscopy program for uninsured patients improves health care utilization. Clin Gastroenterol
Hepatol. 2015; 13:1556–1559. e4. [PubMed: 26296924]
8. Damle A, Andrew N, Kaur S, et al. Elimination of waste: creation of a successful lean colonoscopy
program at an academic medical center. Surg Endosc. 2015:1–6.
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Figure 1. Template for the value stream map of an outpatient clinic

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Am J Gastroenterol. Author manuscript; available in PMC 2016 October 01.