Value stream mapping in healthcare: analysis and simulation in a cancer hospital


  • Marcella Crispim Sarmento Texas A&M University
  • Cathaline Bonafini Sanches Pontifícia Universidade Católica do Paraná
  • Luciano Costa Santos Universidade Federal da Paraíba


Value Stream Mapping, Lean Healthcare, Simulation, Lean Production,


The value stream mapping in association with the discrete-event simulation have been of great contribution to the service operations. In Brazil, the demand for oncology services is expected to grow in the coming years. Taking into account that the Brazilian health services have already been facing some deficiencies, this field has opportunities still not explored to apply the tools mentioned in the hospital context. The objective of this article was to propose improvements to the outpatient clinic of a Brazilian cancer treatment hospital. With that purpose, in loco visits were made to analyze the activities developed in the area, followed by the construction of a value stream map for the current state, the identification of opportunities to improve, and, finally, the proposal and simulation of a future state map. The main problems identified in the hospital were the queues in the medical triage, the use of patients as means to transfer necessary information, loss of patients’ records, non-optimized chemotherapy schedules, and long waiting times to clinical appointments. The proposals for the future state map have shown opportunities to reduce the average lead time of the treatment from 57 days and 16 minutes to 33 days and 6 minutes. The simulation of one of the proposals for the outpatient clinic has shown promising results, with possible execution of the improvement without investments in new resources. On the other hand, a shorter treatment period seems to lead to an expressive increase in the waiting times and the average number of patients in line.


Abdulmalek, F. A., & Rajgopal, J. (2007). Analyzing the benefits of lean manufacturing and value stream mapping via simulation: a process sector case study. International Journal of Production Economics, 107(1), 223-236.

Al-Araidah, O., Boran, A., & Wahsheh, A. (2012). Reducing delay in healthcare delivery at outpatients clinics using discrete event simulation. International Journal of Simulation Modelling, 11(4), 185-195.

Balci, D., Kesen, S. E., & Baykoç, Ö. F. (2007). Adaptability of just-in-time (JIT) philosophy to service systems: a case study. simulation, 83(9), 631-642.

Bertani, T. M. (2012). Lean healthcare: recomendações para implantações dos conceitos de produção enxuta em ambientes hospitalares (Tese de Doutorado, Universidade de São Paulo).

Chakraborttya, R. K., & Paul, S. K. (2011). Study and implementation of lean manufacturing in a garment manufacturing company: Bangladesh perspective. Journal of Optimization in Industrial Engineering, 4(7), 11-22.

Chemweno, P., Thijs, V., Pintelon, L., & Van Horenbeek, A. (2014). Discrete event simulation case study: Diagnostic path for stroke patients in a stroke unit. Simulation Modelling Practice and Theory, 48, 45-57.

CIA - Central Intelligence Agency (2011). The world factbook - country comparison: health expenditures. Disponível em: Acesso em: 13 jan. 2015.

Day, L. W., Belson, D., Dessouky, M., Hawkins, C., & Hogan, M. (2014). Optimizing efficiency and operations at a California safety-net endoscopy center: a modeling and simulation approach. Gastrointestinal Endoscopy, 80(5), 762-773.

Gurumurthy, A., & Kodali, R. (2011). Design of lean manufacturing systems using value stream mapping with simulation: a case study. Journal of Manufacturing Technology Management, 22(4), 444-473.

Henrique, D. B., Rentes, A. F., Godinho Filho, M., & Esposto, K. F. (2016). A new value stream mapping approach for healthcare environments. Production Planning & Control, 27(1), 24-48.

Hydes, T., Hansi, N., & Trebble, T. M. (2012). Lean thinking transformation of the unsedated upper gastrointestinal endoscopy pathway improves efficiency and is associated with high levels of patient satisfaction. British Medical Journal Quality and Safety, 21(1), 63-69.

International Agency for Research on Cancer (2012). GLOBOCAN: Cancer Incidence, Mortality and Prevalence Worldwide. Disponível em: Acesso em: 16 jan. 2015.

Jacobson, S. H., Hall, S. N., & Swisher, J. R. (2006). Discrete-event simulation of health care systems. In Patient flow: reducing delay in healthcare delivery (pp. 211-252). New York: Springer US.

Jimmerson, C. (2009). Value stream mapping for healthcare made easy. Boca Raton: CRC Press.

Kollberg, B., Dahlgaard, J. J., & Brehmer, P. O. (2006). Measuring lean initiatives in health care services: issues and findings. International Journal of Productivity and Performance Management, 56(1), 7-24.

LaGanga, L. R. (2011). Lean service operations: reflections and new directions for capacity expansion in outpatient clinics. Journal of Operations Management, 29(5), 422-433.

Lagergren, M. (1998). What is the role and contribution of models to management and research in the health services? A view from Europe. European Journal of Operational Research, 105(2), 257-266.

Lian, Y. H., & Van Landeghem, H. (2007). Analysing the effects of Lean manufacturing using a value stream mapping-based simulation generator. International Journal of Production Research, 45(13), 3037-3058.

McDonald, T., Van Aken, E. M., & Rentes, A. F. (2002). Utilising simulation to enhance value stream mapping: a manufacturing case application. International Journal of Logistics, 5(2), 213-232.

McLaughlin, D. B., & Hays, J. M. (2008). Healthcare operations management. Chicago: Aupha.

Nasution, J. (2013). Quality service analysis and improvement of pharmacy unit of XYZ hospital using value stream analysis methodology. In IOP Conference Series: Materials Science and Engineering (Vol. 46, No. 1, p. 012022). IOP Publishing.

Organização Mundial da Saúde (2015). Cancer: fact sheet nº 297. Disponível em: Acesso em: 16 jan. 2015.

Robinson, S., Radnor, Z. J., Burgess, N., & Worthington, C. (2012). SimLean: Utilising simulation in the implementation of lean in healthcare. European Journal of Operational Research, 219(1), 188-197.

Rother, M., & Shook, J. (1999). Learning to see: value stream mapping to create value and eliminate muda. Brookline: Lean Enterprise Institute.

Shi, J., Peng, Y., & Erdem, E. (2014). Simulation analysis on patient visit efficiency of a typical VA primary care clinic with complex characteristics. Simulation Modelling Practice and Theory, 47, 165-181.

Suárez-Barraza, M. F., Smith, T., & Dahlgaard-Park, S. M. (2012). Lean service: a literature analysis and classification. Total Quality Management & Business Excellence, 23(3-4), 359-380.

Tortorella, G. L., Fogliatto, F. S., Anzanello, M., Marodin, G. A., Garcia, M., & Reis Esteves, R. (2017). Making the value flow: application of value stream mapping in a Brazilian public healthcare organisation. Total Quality Management & Business Excellence, 28(13-14), 1544-1558.

Werker, G., Sauré, A., French, J., & Shechter, S. (2009). The use of discrete-event simulation modelling to improve radiation therapy planning processes. Radiotherapy and Oncology, 92(1), 76-82.

Yang, T., Wang, T. K., Li, V. C., & Su, C. L. (2015). The optimization of total laboratory automation by simulation of a pull-strategy. Journal of Medical Systems, 39(1), 162.

Yousri, T. A., Khan, Z., Chakrabarti, D., Fernandes, R., & Wahab, K. (2011). Lean thinking: can it improve the outcome of fracture neck of femur patients in a district general hospital? Injury, 42(11), 1234-1237.