Value flow structure and analysis to support Lean initiatives in surgical centers


  • Túlio Fígaro Ulhoa Departamento de Engenharia de Produção, Escola de Engenharia de São Carlos, Universidade de São Paulo
  • Francisco Perazolli Pereira Souza Departamento de Engenharia de Produção, Escola de Engenharia de São Carlos, Universidade de São Paulo
  • Daniel Domarco Rosella Departamento de Engenharia de Produção, Escola de Engenharia de São Carlos, Universidade de São Paulo
  • Kleber Francisco Espôsto Departamento de Engenharia de Produção, Escola de Engenharia de São Carlos, Universidade de São Paulo


Lean, Surgical center, Value Stream Mapping


Lean in hospitals can provide expressive results and benefits for several stakeholders. In these settings, Lean introduction in surgical centers could support improvements, such as staff and patient’s satisfaction increase and reduction of non-value adding time, such as late starts and waiting times for surgeries. To achieve this, Value Stream Mapping (VSM) can be seen as a robust Lean tool, which could support process mapping and identification of wastes and their sources and enable means to prioritize improvements in healthcare process flows. In this paper, a VSM structure for surgical centers is presented in three phases, aiming to identify existing processes and wastes, and suggest improvements based on Lean practices. To support the proposed tool, a literature review of similar approaches was conducted and a case study in a Brazilian hospital was developed, in order to map the surgical center’s processes and exemplify the proposed VSM. This case study also provided practical examples about the VSM introduction and analyzed aspects such as a value aggregation index for the process and the comparison of the proposed tool and other papers in the literature. Based on the proposed approach, it is expected that practical and theoretical studies could use a VSM approach to plan and execute improvement projects in surgical centers and hospitals.


Al‐Hakim, L., & Yan Gong, X. (2012). On the day of surgery: how long does preventable disruption prolong the patient journey? International Journal of Health Care Quality Assurance, 25(4): 322–342.

Aqlan, F., Ashour, O., & Pedersen, A. (2016). Lean process improvement of first case scheduling in operating rooms. Proceedings of the International Conference on Industrial Engineering and Operations Management, 707 – 716.

Bender, J. S., Nicolescu, T. O., Hollingsworth, S. B., Murer, K., Wallace, K. R., & Ertl, W. J. (2015). Improving operating room efficiency via an interprofessional approach. American Journal of Surgery, 209(3): 447–450.

Castaldi, M., Sugano, D., Kreps, K., Cassidy, A., & Kaban, J. (2016). Lean philosophy and the public hospital. Perioperative Care and Operating Room Management, 3: 25–28.

Cima, R. R., Brown, M. J., Hebl, J. R., Moore, R., Rogers, J. C., Kollengode, A., Amstutz, G. J., Weisbrod, C. A., Narr, B. J., & Deschamps, C. (2011). Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. Journal of the American College of Surgeons, 213(1): 83–92.

Collar, R. M., Shuman, A. G., Feiner, S., McGonegal, A. K., Heidel, N., Duck, M., McLean, S. A., Billi, J. E., Healy, D. W., & Bradford, C. R. (2012). Lean management in academic surgery. Journal of the American College of Surgeons, 214(6): 928–936.

Costa, L. B. M., & Godinho Filho, M. (2016). Lean healthcare: review, classification and analysis of literature. Production Planning & Control, 27(10): 823-836.

Costa, L. B. M., Filho, M. G., Rentes, A. F., Bertani, T. M., & Mardegan, R. (2015). Lean healthcare in developing countries: Evidence from Brazilian hospitals. International Journal of Health Planning and Management.

Criddle, J., & Holt, J. E. (2017). Use of Simulation Software in Optimizing PACU Operations and Promoting Evidence-Based Practice Guidelines. Journal of Perianesthesia Nursing: 1–6.

D’Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9): 1197–1209.

Daultani, Y., Chaudhuri, A., & Kumar, S. (2015). A Decade of Lean in Healthcare: Current State and Future Directions. Global Business Review, 16(6): 1082–1099.

Farrokhi, F. R., Gunther, M., Williams, B., & Blackmore, C. C. (2015). Application of lean methodology for improved quality and efficiency in operating room instrument availability. Journal for Healthcare Quality, 37(5): 277–286.

Fine, B., Golden, B., Hannam, R., & Morra, D. J. (2009). Leading Lean: A Canadian Healthcare Leader’s Guide. Healthcare Quarterly, 12(3): 26–35.

Gayed, B., Black, S., Daggy, J., & Munshi, I. A. (2013). Redesigning a Joint Replacement Program Using Lean Six Sigma in a Veterans Affairs Hospital. JAMA Surgery, 148(11): 1050–1056.

Gil, A. C. (2002). Como elaborar projetos de pesquisa? 4ª ed., São Paulo: Editora Atlas.

Gleich, S. J., Nemergut, M. E., Stans, A. A., Haile, D. T., Feigal, S. A., Heinrich, A. L., Bosley, C. L., & Tripathi, S. (2016). Improvement in Patient Transfer Process From the Operating Room to the PICU Using a Lean and Six Sigma-Based Quality Improvement Project. Hospital Pediatrics, 6(8): 483–489.

Glover, W. J., van Aken, E. M., Creehan, K., & Skevington, J. (2009). Case Study on Using Lean Principles to Improve Turnaround Time and First Case Starts in an Operating Room. Society for Health Systems Conference and Expo (Vol. 2).

Graban, M. (2009). Lean hospitals: Improving quality, patient safety and employee satisfaction. CRC Press.

Hassanain, M., Zamakhshary, M., Farhat, G., & Al-Badr, A. (2017). Use of Lean methodology to improve operating room efficiency in hospitals across the Kingdom of Saudi Arabia. International Journal of Health Planning and Management, 32(2): 133–146.

Henrique, D. B., Rentes, A. F., & Filho, M. G. (2016). The Management of Operations A new value stream mapping approach for healthcare environments. Production Planning & Control, 27(1): 24–48.

Hines, P., & Rich, N. (1997). The seven value stream mapping tools. The International Journal of Operations & Production Management, 17(1): 46–64.

Hyder, J. A., & Hebl, J. R. (2015). Performance Measurement to Demonstrate Value. Anesthesiology Clinics, 33(4): 679–696.

Longo, M., & Masella, C. (2002). Organisation of operating theatres: an Italian benchmarking study. International Journal of Operations & Production Management, 22(4): 425–444.

Matos, I. A., Alves, A. C., & Tereso, A. P. (2016). Lean Principles in an Operating Room Environment: An Action Research Study. Journal of Health Management, 18(2): 239–257.

Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean thinking in healthcare: A realist review of the literature. Quality and Safety in Health Care, 19(5): 376–382.

Modgil, V., Gordon, K., Mak, D., Liu, S., & Gommersall, L. (2013). Is percentage theatre utilisation data an accurate predictor of cost-effectiveness and performance in urology? Journal of Clinical Urology, 6(4): 254–257.

Ohno, T. (1988). Toyota Production System: Beyond Large-Scale Production. Portland Productivity.

Patterson, P. (2010). Lean project helps to revitalize and SPD. OR Manager, 26(3): 1–5.

Purbey, S., Mukherjee, K., & Bhar, C. (2007). Performance measurement system for healthcare processes. International Journal of Productivity and Performance Management, 56(3): 241–251.

Radnor, Z. (2011). Implementing Lean in Health Care: Making the link between the approach, readiness and sustainability. International Journal of Industrial Engineering and Management (IJIEM), 2(1): 1–12.

Ramos, P., Bonfá, E., Goulart, P., Medeiros, M., Cruz, N., Puceh-Leão, P., & Feiner, B. (2016). First-case tardiness reduction in a tertiary academic medical center operating room: A lean six sigma perspective. Perioperative Care and Operating Room Management, 5(December): 7–12.

Rother, M., & Shook, J. Learning to see: Value stream mapping to add value and eliminate muda. Lean Enterprise Institute.

Schwarz, P., Pannes, K. D., Nathan, M., Reimer, H. J., Kleespies, A., Kuhn, N., Rupp, A., & Zügel, N. P. (2011). Lean processes for optimizing or capacity utilization: Prospective analysis before and after implementation of value stream mapping (VSM). Langenbeck’s Archives of Surgery, 396(7): 1047–1053.

Singh, S., Remya, T., Nair, D., & Nair, P. (2014). Lean six sigma application in reducing nonproductive time in operation theaters. The Journal of National Accreditation Board for Hospitals & Healthcare Providers, 1(1): 1–6.

Souza, L. B. De. (2009). Trends and approaches in lean healthcare. Leadership in Health Services, 22: 121–139.

Stoutzenberger, T. L., Kitner, Samantha, A., Ulrich, B. L., D’Silva, I., & Shah, M. (2014). Using lean strategies to improve OR efficiency. OR Manager, 30(1): 1–4.

Tortorella, G. L., Fogliatto, F. S., Anzanello, M., Marodin, G. A., Garcia, M., & Esteves, R. 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.

Valsangkar, N. P., Eppstein, A. C., Lawson, R. A., & Taylor, A. N. (2017). Effect of lean processes on surgical wait times& efficiency in a tertiary care veterans affairs medical center. JAMA Surgery, 152(1): 42–47.

Warner, C. J., Walsh, D. B., Horvath, A. J., Walsh, T. R., Herrick, D. P., Prentiss, S. J., & Powell, R. J. (2013). Lean principles optimize on-time vascular surgery operating room starts and decrease resident work hours. Journal of Vascular Surgery, 58(5): 1417–1422.

Womack, J. P., & Jones, D. T. (2004). A mentalidade enxuta nas empresas: elimine o desperdício e crie riqueza. 6ª ed., Editor Campus.

Yin, R. K. (2001). Estudo de caso: Planejamento e Métodos. 2ª ed., Bookman.