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A General Framework for Lean Transformation of

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Conference Paper March 2015
DOI: 10.1109/IEOM.2015.7093901

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A General Framework for Lean Transformation of Hospitals

Ting Yu1, Kudret Demirli2.1 and Nadia Bhuiyan1
1
2
Department of Mechanical and Industrial Engineering
Department of Industrial and Systems Engineering
Concordia University
Khalifa University of Science, Technology & Research
Montreal, Canada, H9R 5S2
P.O Box : 127788, Abu Dhabi, UAE
yu_ting@ecs.concordia.ca, kudret.demirli@kustar.ac.ae, nadia.bhuiyan@concordia.ca
AbstractThe quality of healthcare services has been
negatively affected by long waiting times in hospitals.
Additionally, surging patient care demand, caused by a growing
and aging population, results in pressures of high cost and
increased capacity requirements in healthcare services. With
limited resources and increasing demand, healthcare institutions
are exploring approaches to do more with less. Lean is one such
technique, aiming at creating continuous flow by eliminating
waste while maximizing customer value. Although healthcare
practitioners have been proposing different lean implementation
solutions for healthcare services in different types of clinics, the
applications are fragmented and cannot be generalized in all
healthcare settings. In this paper, three systematic lean
frameworks are defined based on various healthcare features and
traditional lean systems, specifically replenishment pull and
sequential pull systems. Three healthcare domains, the
emergency department, outpatient clinic and inpatient unit, are
studied to help develop these frameworks. The purpose of
proposed frameworks is to provide a guideline to transform
traditional healthcare systems into lean systems. A case study in
an outpatient clinic is presented subsequently. After current
processes are mapped and analyzed using value stream mapping,
an improved patient flow is achieved by applying the outpatient
clinic lean framework.
KeywordsLean Healthcare, Lean Manufacturing, VSM,
replenishment pull, and sequential pull

I. INTRODUCTION
A healthcare system consists of all facilities that deliver
direct or indirect services to promote or keep individuals
health condition [1]. It plays an integral part in a persons life.
However, long waiting times in healthcare services cause
patient dissatisfaction and diminish healthcare quality. Faced
with decreasing healthcare quality, healthcare industries are
attempting to operate healthcare service at better levels. Due to
the pressing need for improved healthcare services caused by a
growing and aging population, healthcare expenditures are
soaring [2]. Consequently, healthcare organizations have been
under severe pressure to improve quality for their patients and
this requires doing more with less.
Recently, concepts and methodologies from the
manufacturing sector, such as lean manufacturing, have been
adopted in healthcare. In lean, the focus is on continuous
workflow while minimizing waste and maximizing customer
value. By adopting a lean approach, healthcare institutions can
benefit from improving patient care as well as saving time and
other resources. The lean philosophy has been adapted from
traditional manufacturing to healthcare sectors because of the

strong resonating success in the manufacturing environment.

Researchers interests in lean healthcare has increased in recent
years. Existing work covers several healthcare areas, as for
example, Emergency Departments (ED) [3], outpatient clinics
[4], colorectal department [5]. Although some successes
achieved, applications of lean in healthcare are fragmented and
non-reproducible [6]; most of them only concentrate on
selective tools, such as Kaizen events, rather than a systemwide implementation. Consequently, a unified lean framework
is required for healthcare services.
In this paper, we present an overview of the lean
philosophy and lean healthcare in Section 2, followed by
distinctions between healthcare and manufacturing settings.
We give a gross taxonomy for healthcare services in light of
healthcare features and traditional lean systems in Section 3,
and then three lean healthcare frameworks are suggested.
Subsequently, in Section 4, an outpatient clinic case study is
presented. Finally, we conclude with some remarks and future
perspectives of research in Section 5.
II. BACKGROUND
A. History of Lean Manufacturing
Lean concepts, derived from the Toyota Production System
(TPS), were developed in the 90s by researchers at the
Massachusetts Institute of Technology. The first application
and success of lean in manufacturing was shown by Womack
and Jones in the book The Machine That Changed the World
[7]; subsequent applications are found in countless
manufacturing companies. Lean is a set of tools and techniques
for improving processes, quality and reducing costs by
eliminating wastes from the customers perspective.
The initial concept of lean was defined as five principles, a
roadmap of the course of actions to follow and potential areas
of improvement, in 1996[7]:
Define value. Define value-added activities that meet
end customer by product family.
Value stream mapping. Value Stream Map (VSM) is a
lean management and visualization method showing
how tasks and information flow from its beginning
through to the end of the stream [8]. It is a presentation
of a state of all the steps in the value stream for each
product family, and time stamps from leadoff to the
final process. Elimination of wastes is required at the
end of this stage.

978-1-4799-6065-1/15/$31.00 2015 IEEE

 Create flow. Establish a system without product flow

interruption so that underlying waste can be more easily
identified and addressed.
Establish pull. Develop controlled inventories where
continuous flow could not be achieved or pulled by the
next downstream activity.
Pursue perfection. Undertake cyclic activities that
assure the sustainability of lean manufacturing
improvements.
Introducing lean principles relies on the identification and
elimination of waste. Thus the understanding of waste in lean
is critical to the success of lean transformation. According to
the lean methodology, there are two types of activities: valueadded activities, non-value-added activities. Any individual
step within the value stream that contributes directly to the end
value is considered a value-added activity, and anything does
not improve or add value to the customer are non-value-added
activities. Non-value-added activities include incidental
activities, which should be reduced, and wastes that can be
eliminated. Ohnos wastes comprise seven activities, namely,
defects, overproduction, overprocessing, inventory, motion,
transportation and waiting [9].
Applying rigorous lean principles, lean manufacturing has
gained a high reputation in industry, bringing more profit,
higher quality and competitiveness at a comparatively low cost.
B. Review of Lean Healthcare
As long waiting times reduce healthcare quality,
practitioners have recognized that lean is a remedy for
healthcare under the pressure of limited resources and a
growing patient population. The first implementation of lean
healthcare, which aimed to reduce waiting time in an Accident
and Emergency Department, was in the United Kingdom, 2001
[10]. Subsequently, lean concepts in healthcare have been
applied widely.
Although there are considerable successes of lean
applications in healthcare services, methodologically, the
majority of studies about lean healthcare are not rigorous in
comparison with other improvement methods. Practical lean
approaches are diverse and selective in healthcare settings. A
typical isolated case study, focusing on introducing ICT
(Information Communication Technologies), was found in a
urology clinic. Although this ICT facilitates the delivery of
superior healthcare, and reduces manual document checking
activities as well as partial waiting time of patients, quick
wins were achieved by this event but this does not easily
engender radical and ongoing redesign of core procedures [11].
Similarly, Naik et al.[12] adopted multiple improvement tools,
such as flow mapping, A3 and rapid improvement events
(RIEs), in a public hospital ED. All these tools assure a
comprehensive aspects of potential improvements, nonetheless,
these improvement activities were a constellation of poorly
connected interventions but joined under the topic of lean
transformation; lean resembles a trouble-shooting kit for
addressing pre-existing problems in these applications, leading
to local optimizations and even repetitive work, rather than
increasing value or quality driven by the customers value.

Moreover, the adoption of lean healthcare lacks systematic

and scientific lean approach, although some of them consider
lean principles as their roadmap. Rodriguez [5] implemented
lean method in a colorectal department. Value stream mapping
tool was used to present and analyze the as-is and future states,
an improved patient flow was achieved by following five lean
principles. However, the limitation of this research is lean
principles do not systematically applied; the author concerns
more about waste elimination instead of creating pull. Ng et al.
[13], realised that waiting times in the ED has generate issues
of overcrowding, patient dissatisfaction etc., so based on waste
elimination, they improved workplace organization and created
a communication mechanism, and then continuously refine
improvements using lean principles. Though, due to the lack of
fully understanding lean principles and the existing system,
most improvements were fragmented activities, which were
directed towards the hospital managerial level. Related to this,
the impact of lean could be limited and may even revert to the
previous environment if there is no ongoing support and
development.
Also, it is worth considering that the literature suggests a
multitude of variabilities in the implementation of lean with
differences not only in approach but in scope. The book titled
Making hospitals work by Baker et al.[14] is based on the
NHS in the UK. This effort aimed at applying lean in an ED to
inpatient wards. By controlling the discharge rate, they
regularly emptied beds for admitting patients. Athawale, Wang
and Magill also concentrated on the reduction of time between
ED admission and inpatient bed assignment [15]. For
outpatient clinic, Fulton et al. adopted lean in a wound clinic,
streamlining patient, staff, and information flow [16]. Multifunctional process map and VSM presented the course of
clinical process and addressed a variety of process
improvement issues, coupling with other qualitative and
quantitative systems engineering tools. In an acute
rehabilitation service centre, Venkateswaran et al. [17]
demonstrated an application of lean for acute inpatients by
adopting Kaizen events to address inefficient work processes in
scheduling, communication among medical staff and traveling
to the therapy location. Similarly, many other departments
have reported the benefits they have obtained using lean
concepts. For instance, they looked into optimizing operating
room capacity utilization [18], improving waiting times at a
medical oncology unit [19], or reducing lead time of
medication deliveries from the hospital pharmacy to the
clinical wards [20]. In these and other cases, the results
reported were tangible outcomes such as reduced waiting
times, decreased costs and improved quality, as well as
intangible ones such as higher staff morale and increased
customer satisfaction; however, applications used different lean
solutions to deal with different healthcare situations, even
though some of these healthcare areas have commonalities in
the way they provide their services.
Briefly, healthcare practitioners have been proposing
different lean solutions or implementations for different types
of clinics. However, multiple case studies have demonstrated
that healthcare organizations have not fully institutionalized
lean to Toyotas level, which was developed to a structured and
comparatively mature methodology; applications are

fragmented and cannot be generalized to different settings,

giving rise to the problems of non-reproducibility in practical
lean applications.
C. Comparison of Lean Manufacturing and Lean Healthcare
There are several differences between lean in
manufacturing and in healthcare, contributing to a less
developed lean healthcare system.
First, customers and products in healthcare are patients.
Patients receive treatments provided by the medical staff for
the purpose of recovery. Since the patient is the customer, what
makes lean different from other process improvement
initiatives is that it is driven by the customers perception of
value. A traditional definition of value in manufacturing is a
function of cost, quality and customer satisfaction. Compared
to companies, value in healthcare services is characterized by
1) the unawareness of the price of the services received, 2) the
vagueness of service quality rating, and 3) the difficulty of
calculating service delivery expenses. Therefore, Breuer [21]
defined that patient value consists of any process or action
which increases patient satisfaction.
Second, the functions and management structures in
manufacturing and in healthcare are different. The correlative
and sequential functions in manufacturing industries consist of
receiving, material management, manufacturing, assembly,
testing, delivery and logistics; but hospitals cope with the
independent or sometimes staggered functions such as ED,
acute inpatient care, rehabilitation or diagnostic center.
Referring to management structures, manufacturing factories
are most often hierarchical, thus the activities performed by
employees are delegated by managers; whilst in healthcare
organizations, doctors are contractors instead of employees and
their job is to prevent diseases or cure patients autonomously
[22].
Finally, it is evident that healthcare is largely capacity-led
and budget-focused, hence there is limited ability to influence
demand, or to re-use freed-up resources to grow the business
[23]. Enterprises are capable of re-allocating resources by
growing the existing business, provided customer demand is
manageable. However, there appears to be little evidence to
suggest healthcare settings could control demand in this way.
Conjointly, these three breaches potentially pose severe
constraints of the impact that lean in public healthcare
organizations and leads to the requirement of generalized
frameworks for lean healthcare. In the following section, three
systematic frameworks, relying on traditional lean frameworks
and three defined healthcare domains, are introduced.
III. LEAN SYSTEMS AND HEALTHCARE DOMAINS
Methodologically, the large proportion of studies in lean
healthcare are not comprehensive and rigorous. The blind copy
of lean manufacturing principles is affirmed to be not
applicable in healthcare because of the aforesaid gaps between
healthcare and manufacturing. In consequence, according to
the existing traditional lean systems, an adjusted
methodological framework is discussed and then linked to the
healthcare domains defined in the following section.

A. Basic Types of Lean Systems

In lean manufacturing, there are two basic types of Lean
systems: replenishment pull system and sequential pull system
[24]. Both of them are discrete systems; to differentiate these
two systems, the following factors are taken into consideration:
demand variations, customized products, product volume, and
duration of lead times.
More precisely, a replenishment pull system, also known as
a supermarket or fill-up system, is the most common type with
low demand variation, high volume, long lead time, and no
customized product (ideally). In this system, each process
holds the products in a store called a supermarket. A
supermarket, keeping supply in downstream processes, is a
controlled inventory. Whenever the supermarket is consumed
by a downstream process, the upstream process has to
replenish what has been depleted. Kanban or other type of
information is applied at the pacemaker in such a system to
trigger withdrawal and replenishment activities. A pacemaker
is only one scheduling point in the system and reduces the need
for coordination[24]. This system works well when demand is
steady and the schedule can be set at least a few weeks in
advance. Output does vary at the pacemaker when there is
mixed-model production in a value stream, but a continuous
workflow is obtained by the pull signals generated by the
pacemaker, ensuring that only the types of products which are
needed are produced. Figure 1 demonstrates the replenishment
pull system.
Schedule
Department

Customer

OXOX

Process 1

Process 2

shipping

Fig. 1. Replenishment Pull System

In a sequential pull system, the schedule is often sent to an

upstream process a few days ahead of lead time, making sure
that products are made-to-order. This pertains to high
demand variation, and high volume of customized product
system. By using FIFO lanes, the overall system inventory is
minimized and kept in a consistent sequence. FIFO has the
principle of maintaining a precise production and conveyance
sequence by ensuring that the first part to enter a process or
storage location is also the first part to exit [24] . Variations of
daily production at the pacemaker result from the products of
higher work content, but this pulse is absorbed by FIFO lanes.
In manufacturing, an internal supplier fills FIFO lanes while
the internal customer withdraws. If the lanes are full, the
supplier must stop producing until there is empty spaces in the
FIFO lane. Thus, overproduction is prevented. A sequential
system requires reliability, high quality and strong
management to be well-maintained. Compared with the
replenishment pull system, the sequential pull system

encompasses less waste and is more time and volume flexible

in building custom products. Nonetheless, when the pacemaker
is in the most upstream point, the product has to flow in FIFO
lanes through the remaining steps. This causes larger FIFO
lanes, if the downstream processes pulse differently, and
results in increased lead time. Figure 2 shows a sequential pull
system.
Schedule
Department
Customer

Process 1

Process 2

shipping

FIFO

FIFO

Fig. 2. Replenishment Pull System

In summary, typical characteristics of two different lean

systems are summarized below in Table 1.
TABLE I.
Trait

TRAITS OF LEAN SYSTEMS

Lean system
Supermarket pull

Sequential pull

System attribute

Discrete system

Demand variation

Low

High

Customized product

No

Yes

Product volume

High

Low

Lead time duration

Long

Short

B. Defined Healthcare Domains

A healthcare system delivers services, such as primary
healthcare, hospital care, community care specialized services
and pharmaceutical care etc., to promote or keep individuals
health conditions whenever patients need them. Hospital-based
interventions can be generalized into non-appointment based
and appointment based hospital services.
The most typical non-appointment based department in
hospital is the Emergency Department which naturally have
uncontrolled in-flow of patients with a variety of treatment
needs. Patients come to the ED either on their own or by
ambulance, prioritized by nurses or other medical practitioners
into several levels before treatment. For example, in Canada,
there are five levels, resuscitation, emergent, urgent, less urgent
and non-urgent, from level I to level V. The subsequent
procedure is doctor consultation, followed by relevant
treatments or tests, and final decisions are hospitalization,
discharge or admission [25].
Appointment based services, on the other hand, have
controlled and predictable demand. Both types of services can
act as outpatient clinics (patients go home after the treatment)
and inpatient settings inpatient units (patients stay for recovery)
which further complicates the problem. Outpatient clinics deal
with patients that come for doctor consultation or one day

treatment. Referred by other departments or general physicians,

outpatients arrive at the clinic in a predetermined time slot by
appointment scheduled in advance. A typical outpatient flow is
as follows: a patient arrives and waits for registration; based on
the patients appointment time, the patients arrival time,
availability of nurses, and availability of exam rooms, the
patient has certain tests first before he/she consults the medical
doctor and then gets discharged [26]. Inpatient service takes
care of patients whose conditions require admission to a
hospital for a period of time [27]. Procedures for inpatients are
more complex and even unfixed; the total hospital experience
for inpatients can be simply summarized as admission,
intervention, and discharge. It is noteworthy since inpatients
stay with medical providers, the control of the flow is more
accessible compared with aforesaid two services.
So far, three hospital-based domains are defined as
emergency services and non-emergency services which
consists of outpatient clinic and inpatient care. In what follows,
based on both healthcare features and traditional lean systems,
systematic lean healthcare frameworks are proposed.
C. Lean System for Hospitals
Limitations of existing lean healthcare applications, such as
fragmented activities, cause partial lean phenomenon, to be
precise, non-repetitive, restricted and unsustainably lean
implementations, in aforesaid healthcare domains; lean
frameworks, or methodological supports, therefore, are
urgently required to better adopt lean in these domains by
adjusting two original lean systems. For this reason, Table 2
summarized typical traits of each healthcare domain in light of
current studies and will be linking to different traditional lean
systems.
TABLE II.
Trait
Pre-request
Patient source
Patient outlet
System attribute
Expected
lead
time druation
Demand
prediction
Demand
variation
Demand volume
Recommended
control point
Suggested Lean
system

TRAITS OF HEALTHCARE DOMAINS

Emergency
service

Healthcare domains
Outpatient
Inpatient unit
clinic

Nonappointment
Walk-in,
ambulance
Discharge,
inpatient,
outpatient

Appointment

Appointment

Prescheduled,
ED

Prescheduled

Discharge,
other units

Discharge

Discrete System
Short

Relatively long

No

Yes

Yes

High

Low

Low

Varying

High

Upstream
process
(Triage)
Sequential
Pull

Downstream
process
(Discharge)

Downstream
process
(Doctors)

Replenishment Pull

With respect to healthcare domains, a common problem is

long waiting time [13], while inpatient service and outpatient
clinic are experiencing the issue of long LOS [27], patient

delay and cancellation respectively [28]. Patients source and

outlets of each healthcare services depend on the type of
hospital resources required and medical reaction time patients
needed. Also, Lean solutions vary depending on the
characteristics of each healthcare domain. With regards to the
ED, unpredictable demand, high demand variation, and
expected short lead time etc. has the characteristics of the
sequential pull system. The important aspect of such systems is
to adjust cycle time to maintain a steady flow of patients
through the system for an acceptable waiting time. Outpatient
clinic is akin to the supermarket pull system because of its
predictable demands, low demand variation, high patient
volume etc. Additionally, outpatient clinics usually contain two
subsystems; one is with physical occupation of beds or chairs
such as outpatient surgeries, and the other one is only with
doctor consultation such as ambulatory clinics. The first one
requires supermarkets to admit new patients while the second
one has the bottleneck of doctors, the very downstream
process. Inpatient service is also analogous to the supermarket
pull system. Some patients arrive based on a schedule and
some from ED, etc. (where allowances for such patients are
made in the schedule). There is a finite number of available
beds and steady discharge of beds controls the in-flow of
scheduled patients. The imperative point for both outpatient
clinic and inpatient service frameworks are to adjust takt time
to meet cycle time of the scheduling point, and to smooth
patient flow by creating supermarkets for the minimized
waiting time and appropriate patient population per day; then
more supermarkets can be established to level takt times of
processes. Moreover, supermarkets for all healthcare domains
contain FIFO lanes inside to keep healthcare systems in a
first-in-first-serviced manner.
IV. CASE STUDY
An outpatient cancer clinic in a Local Community Hospital
covers the patient care of prevention, diagnosis, treatment of
cancer along with, psychological, social, and nutritional
support. Committed to fighting cancer through clinical and
basic cancer research and patient care, this center consists of 4th
and 5th floors, which are dedicated to fundamental research,
and 7th to 10th floors providing patient care. Currently, this
clinic confronts a growing patient population, therefore it has
witnessed a growth in their patient demand, creating long
waiting times for the patients as well as decreasing healthcare
quality. The scope of this case study focuses on the
improvement of patient flow on clinical areas of 7th to 10th
floors, reducing long waiting times and accommodating more
demand.
A. Current State
As patients arrive at the clinic, based on their appointments,
they check in at the registration desk on the 7th, 9th or 10th floor
according to their type of cancer. Once checked in, the patients
draw their blood in the corresponding blood test station and
have their weight and height recorded. Oncologist consultation
happens after a student or resident examination; based on
patient condition, oncologists recommend further tests,
consultations or chemotherapy treatments, followed with
appointment booking on the floor where patients are seen by

oncologists. In the case that a patient is prescribed at least one

chemotherapy protocol, the patient books a request which will
be sent to 8th floor, where patients get their chemotherapy
treatments.
One prescription of a period of chemotherapy treatment
comprises several cycles with a fixed protocol. Patients, called
cycling patients, repeat cycles on a weekly or monthly basis.
Each cycle lasts from 30 minutes to 6 hours, depending on the
protocol prescribed. Before each cycle, a recent blood sample
is an obligation, sometimes followed by an oncologist
consultation. A patient with unqualified blood result or has
reactions during chemotherapy cycles is sent back directly to
oncologist with an advanced, high priority appointment
corresponding to 7th, 9th or 10th floor, and then start a new
protocol if necessary. All protocols are prepared in a pharmacy
which is on 8th floor and dedicated to this oncology clinic.
Patient classification for chemotherapy treatment are R1, R2,
and R3, which represents patients of 30minutes to 120 minutes
chemotherapy infusion time, patients of 120 minutes to 240
minutes chemotherapy infusion time, patients of 240 minutes
to 360 minutes chemotherapy infusion time respectively. R1
patients, accounting for 50%, are treated in a one-day treatment
pattern while others, taking up 30% and 20%, have their
treatment in two-day pattern. Two-day treatment may happen
several days after depending on availabilities of chemotherapy
chairs.
Currently, the clinic is facing the problems of long waiting
times from the perspective of patients and in terms of the clinic
itself, medical staff are catching up on their daily work, and
have to work overtime to finish dealing with all patients. Nonstreamlined patient flow, various unsynchronized systems and
clogged hospital facilities are causing frustration, stress, and
discomfort for both patients and staff. Primarily, patients are
pushed in the system from upstream process to downstream
process, as a result, stagnated patients are scattered all over the
clinic. And in this particular case, a lot of patients accumulated
between 7th and 8th floor, not physically but in a waiting list.
Information is mainly transmitted by patient charts. The
archive area occupies half of the registration section and this
requires one clerk dedicated to filing and transporting
throughout the clinic. Additionally, as software systems are
numerous, and each software is dedicated to a certain
procedure, medical staff have to check several pre-printed
schedules for data synchronization and error correction.
Besides, two support services, blood laboratory and pharmacy
do not cooperate well with this clinic and this creates long
waiting times. While each patient blood testing procedure takes
15 minutes, since the clinic batches blood samples, the blood
processing time stretches to more than 2 hours. Similarly, the
pharmacy prepares patients medications in batches, which
leads to unnecessary patient waiting times.
The current VSM is showed in Figure 4. In order to better
understand the patient and information flow, in this current
VSM, we ignored some lean icons, such as inventory triangles
and data boxed underneath process boxes. An additional time
ladder shows the length of time patients spent in a two-day
treatment. In this case study, we consider the time when
patients wait at home as waiting time, as long as they do not
complete their treatments. Therefore, value-added time of

Medivisit

9th 10th
floor

EndoVault And
other systems

New
Prescription

Patient
Charts

Follow-ups

Scheduler

Pharmacy
Lab

Cycling Consultation

Patients with Reactions

Patients with Bad Blood Tests

Registration 7th

Drop-in

Home

Blood Lab

1 day

Blood Test
Registration 7th

Blood Test
Registration 8th

Oncologist
Consultation Dr.

Oncologist Student or
Resident Dr.

Blood Test 7th

Blood Test 8th

SurgicalStudent or
Resident Dr.

Surgical
Consultation Dr.

Gynecologic Student
or Resident Dr.

Gynecologic
Consultation Dr.

Appointment
Oncology

Registration
8th 1

Appointment
Hematology

Registration 8th
2

Chemotherapy
Station 1

Chemotherapy
Station 2

Pharmacy
Reception

Weighing
Hematologist Student
or Resident Dr.

Hematologist
Consultation Dr.

Total lead time:

637-967 for CP
118.5-422 for PF1
809-few days for PF2
929-few days for PF3

Cycling patients
2min

0.5min
1min

Registration

2min
0.5min

Bloo d
Registration

1min
3min

Bloo d Test

10-60min
1.5min

Weighing

30min

1min

15min

15-60min

Stu dent o r
Residen t

Oncologist

2min
1min

Appointmen t

0.5min
0.5min

Pharmacy

10-120min
0.5min

30-360min

Registration 8th

Chem o

More than 1 day

Value-added time:
323.5-363.5 for CP
73-203 for PF1
163-293 for PF2
283-413 for PF3

0.5min

Registration 8th

Fig. 4. Current VSM for Outpatient Oncology Clinic

cycling patients is 5% to 38% of total lead time, 637-967

minutes, since cycling patients have to draw their blood in the
previous day before treatment. For the rest of patients, total
lead time is 119-422 minutes and the ratio of value-added time
is 48%-58% total lead time for one-day treatment (R1
patients); for two-day treatment, R2 patients have the lead time
of 809 minutes or more, but less than 23% value-added time,
while, with respect to R3 patients, the total lead time of 929
minutes to few days contains less than 48% value-added time.
In summary, assuming that two-day treatments are completed
in two days, which may actually finish within two weeks, for
all patients, the percentage of value-added time is 28%-32%
total lead time.
B. Proposed Future State
For the purpose of improving patient flow and information
flow in this outpatient clinic, reducing long waiting times and
meeting more demands, a future VSM on the basis of the
replenishment pull system is established for this clinic as
demonstrated in Figure 5, where CP represents cycling patient,
FU for follow-up, PR for cycling patient with reactions, CPD
means cycling patient with doctor consultation, PBB stands for
cycling patient with bad blood result, NP implies new patient,
RCP for regular cycling patient and PF for patient family, P
means protocol, B presents blood result, and M for medication.
This future state map pertains to the replenishment pull
system, because of its predictable patient population,
predetermined patient types, high patient volume and
requirements of treatment chair supermarkets. In this case
study, we first assume that pharmacy and blood laboratory are
improved and are able to provide what the clinic needs on time.
After waste elimination and information centralization, we start

with identification of patients families depending on protocol

infusion time, we have three families: PF1, PF2 and PF3. It is
analogous to the previous patient classification, R1, R2 and R3.
Employing offset sequencing, from the chosen pacemaker,
very downstream process, chemotherapy station, we empty
chairs for patient families at the right time (according to the
schedule), and receive prescheduled medications from
pharmacy by FIFO lanes. Since chemotherapy station is our
pacemaker to control the throughput of this clinic, a critical
point here is to adjust takt time to meet cycle time of this
station to smooth patient flow by creating supermarkets for the
minimized waiting time and appropriate patient population per
day. Going back to further upstream, there is a supermarket
between appointment process and chemotherapy treatment
process; it accommodates all patients from 7th, 8th and 9th floor.
In this supermarket, patients are separated into three patient
families and are waiting their treatments in corresponding
FIFO lanes. Cycling patients, whose treatment cycles are fixed
in a certain day, CPD and RCP in this clinic, get their
chemotherapy treatments through a prioritized FIFO lane in
this supermarket. As cycling patients are getting their
treatments, the remaining patients are waiting in the
corresponding FIFO lanes, while pharmacy is preparing their
medications. After all cycling patients are accommodated by
chemotherapy stations, remaining patients are able to send their
need chair signal to the supermarket. At this time, the
chemotherapy process should supply a chair for those patients
and pharmacy should provide their medications as well. Pulled
from this supermarket, patients smoothly flow from the
upstream process, doctor consultation or blood test etc., to
chemotherapy treatment stations. Additionally, A few
supermarkets are created in other points of this clinic, holding
an amount of patients that upstream process treated. Each

Medivisit

OXOX
Follow-ups

Home

P1(B1), P2(B2), P3(B3)...

th

th

9 10 F

New
Prescription

Pharmacy
Lab
Cycling
Patients

Supply
Patients

Need
Patients

Student or Resident Dr.+

Oncologist Consultation

PBB

Need
Chair

Registration 7th

PR

PBB
Student or Resident Dr.+
Surgical Consultation Dr.

FU

NP

Blood Lab

FU

PR

Appointment

Weighing

CPD

NP

FU

CPD

FU
NP

CPD

CPD

PF1

Chemotherapy
Station 1

PF2
Registration 2

PF3

Chemotherapy
Station 2

CPD+RCP
Need
Patients

Student or Resident Dr.+

Hematologist Consultation Dr.

NP

Registration 1

PBB
PR

NP
Student or Resident Dr.+
Gynecologic Consultation Dr.

Blood Test 7th

Supply
Chair

RCP(one
day+0.5min)

Total lead time:

635-965 for CP
108.5-528 for PF1
198.5-618 for PF2
258.5-738 for PF3

Supply
Patients

CP
0.5min

0.5min

0.5min

0-30min

1min

2min

1.5min

Registration

Blood Test

Weighing

O.5min
15-60min

Consultation

0.5min for CP
0-300min for others

0.5min
1min

Appointment

0.5min

Registration 8th

30-360min

Chemo

Value-added time:
32.5-362.5 for CP
47.5-272.5 for PF1
137.5-272.5 for PF2
257.5-392.5 for PF3

Fig. 5. Future VSM for Outpatient Oncology Clinic

process simply treated to replenish what is withdrawn

from its supermarket. These supermarkets are implemented for
leveling different process takt times in the system and FIFO
lanes in these supermarket are used for patient prioritization
and keeping patients in a first-in-first-serviced manner.

appropriate future state map. Therefore clinics will be able to

treat their increasing patient population, efficiently utilize
existing resources while minimizing patients waiting time.

As a result, for cycling patients, lead time is 635-965

minutes, and value-added time is 5%-38% of the lead time,
because we couldnt change the schedule for cycling patients in
this oncology clinic. With regards to remaining patients,
besides PF1 patients, 83% PF2 patients and 43% patients are
infused their medications in the same day. Specifically, for
PF1, PF2, PF3 patients, their lead times are 109-528 minutes
(lead time increased compared with current VSM because we
assume that there are patients waiting as long as 300mins in the
system and, in fact, this rarely happens if patients come based
on their schedule), 199-618 minutes and 319-738 minutes, and
their value-added time are 35%-44%, 44%-69%, and 53%-81%
of their respective lead times. Since working hours in this
outpatient clinic is 600 minutes and there are patients with lead
time of more than 600 minutes, an alternative is working
overtime to finish all patients, otherwise, patients should be
sent home given preferential treatment the next day. In total,
value added time is improved to 45%-70.7% of total lead time
compared with current state of 28%-32% of total lead time.

Lean provides an opportunity for healthcare services to do

more with less. As long waiting time is negatively affecting
healthcare quality, many lean practitioners recognized that
developing a lean framework for healthcare, under the pressure
of limited resources and growing volumes of patients, are
imperative. In accordance with different healthcare features,
non-appointment based services and appointment based
services are identified and linked to different traditional lean
systems with suggested basic frameworks: sequential pull and
replenishment pull system. The result of proposed systems is to
provide a guideline to be followed to transform these
traditional healthcare systems into lean systems which together
will help creating a lean hospital, where patients are satisfied
and efficient utilization of resources to deliver high quality
healthcare services are obtained. In the case study in an
outpatient clinic, based on the fundamental replenishment pull
system, we created a lean outpatient clinic and obtained a more
streamlined, controlled patient flow with less waste and shorter
waiting times.

In conclusion, this replenishment pull system provides

oncology clinic with a suggested solution for lean
transformation which can serve as a guideline. This proposed
replenishment pull system is more streamlined and predictable
with acceptable waiting times. By following this framework,
lean practitioners in this clinic will be able to choose the most
appropriate lean model for their services and create the

Our future research will concern the more generic

frameworks from these three healthcare domains and try to
involve more healthcare support services which influence
healthcare deliveries such as blood laboratory, even though
patients do not have any physically contact with them.

V. CONCLUSION

Acknowledgement: This research is partially supported by

Natural Sciences and Engineering Research Council of
Canada (NSERC).
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BIOGRAPHY
Ting Yu is a Ph.D. candidate in Industrial Engineering, studying Lean
healthcare, in the Department of Mechanical and Industrial Engineering
in Concordia University. She obtained B.S and M.Sc. in Industrial
Engineering from Xian University of Technology, China. She was
occupied with two projects relating to Lean Healthcare which aimed at
patients waiting time reduction and patient flow improvement. She has
done research projects about Lean six sigma and Design for six sigma
previously. Her professional interests include Lean Manufacturing, Lean
Healthcare Design, simulation and Six Sigma Management.
Kudret Demirli received the B.Sc. and the M.Sc. degrees in Industrial
Engineering from the Middle East Technical University, Ankara,
Turkey, in 1985 and 1988, respectively, and the M.Sc. degree in
Operations Research from Cornell University, Ithaca, New York, in
1990. He received his Ph.D. degree from the Department of Industrial
Engineering at the University of Toronto in 1995. He was hired as an
Assistant Professor in the Industrial Engineering Program at the
Department of Mechanical Engineering - Concordia University in 1995
where he became a Professor in 2011. He is currently the Chair of
Industrial and Systems Engineering Department at Khlaifa University
of Science, Technology and Research.
Nadia Bhuiyan received her B.Eng. in Industrial Engineering at
Concordia University, and her M.A.Sc. and Ph.D. both at McGill
University in Mechanical Engineering. She was an Assistant Professor
at Queens School of Business and a lecturer at McGill University in
Management Science. She became the Associate Director of CIADI in
2003. Dr. Bhuiyan has a number of industrial collaborations with
aerospace companies such as Pratt & Whitney Canada, Bombardier
Aerospace, Bell Helicopter, and CMC Electronics, and is involved in
several CRIAQ (Consortium for Research and Innovation in Aerospace
in Quebec) projects, most recently in Lean Engineering. She works
closely with the aerospace industry in Montreal to research and develop
tools and techniques in lean and to study their application across the
enterprise.