Transformation at the Frontline--A Nurse’s Perspective on Enablers of Outcomes-Based PI: Value Stream Mapping

The Value Proposition for Value Stream Mapping in Healthcare

Those who are well-versed in Six Sigma and DMAIS are familiar with using process maps to define borders and high-level steps. A process map visually describes the flow, sequence, and interactions of related activities from the beginning to the end. From a manufacturing perspective, this makes sense. However, in healthcare every process is patient-centric, including non-clinical processes, and must be viewed from the lens of keeping and creating value for the patient. To identify steps as value added, non-value added, or non-value added but necessary, the clear choice is to utilize a value stream map (VSM).

To keep the focus on the true customer, every process must be viewed from the patient lens, including non-clinical processes. In the laboratory, for example, we must view the widget as the patient’s specimen; in surgery, the patient’s case cart; in records, the patient’s chart; in housekeeping, the patient’s room. Keeping the patient front of mind, ensures everything we do has their best interestsat heart.

Many people interchange a VSM with a process map or even a flow chart, but they are immensely different. A VSM is more than just borders and high-level steps, a VSM:

  • Is a visual tool with real-time data to see and understand the flow from the patient’s perspective.
  • Places a focus on improving the whole process rather than isolated task optimization.
  • Is a road map to improvement--helping to see and eliminate waste while adding value.

Traditional v Value Stream Mapping: Where to Optimize?

In traditional work flows, the focus lies on optimizing what’s directly in front of us; our environment. We rarely consider what happens in preceding processes that directly affect us, or in succeeding processes that our work may impact. Graphically, business as usual can be represented as the following:


A VSM approach has us remove the blinders to look both upstream and downstream. What processes are inputs or are feeding our work? What effect do we have on the next set of processes downstream? Where can we remove waste and add value for the patient? How is my work adding value? Is it something the patient is willing to pay for?


Not all our work may be 100 percent value added, but we must ask what value is derived from each step of the process. Some activities may seem repetitive or non-value added, such as asking the patient about his or her allergies or having another nurse double check the insulin dosage. In this case, there is a safety component incorporated, so these steps may be determined to be either value added or non-value added but necessary.

To enable the patient to see the value, we must set clear expectations, such as: “I’m sure you’ve already discussed your allergies with other staff, however I want to be sure I have them listed correctly” or, “From a safety standpoint, Mrs. Jones, we have all our insulin dosages double checked to ensure you are getting the accurate dose.”

Why Value Stream Mapping?

  • Identifying your current state allows you to see flow.
  • Analyzing your current state allows you see opportunities for improvements in quality, cycle time, lead time, and patient satisfaction.
  • Understanding your current state allows you to develop a vision for improved flow.
  • Displaying your current state in your area allows for transparency of the flow and planned improvement work.

Consider that every process has, at a minimum, three versions:


The objective is to get everyone to embrace reality before moving to the ideal. Value stream improvement is primarily a management responsibility. Management must be able to see the overall flow, develop a vision of improvement for the future, and lead the improvement implementation. A current-state map and the effort required to create it are pure waste unless you use it to create and implement a future-state map depicting where the process will be (realistically) in 12 months.

Choose a process

Mapping for the Future

While creating a VSM requires more time investment up front, the information it yields is of far greater value than a process map, particularly because its utilization sets the stage for the future state. Your future state VSM is:

  • a vision of the health care experience, process, or service flow without waits, stopping, batching, mistakes, or other waste.
  • a document used to drive detailed implementation plans.
  • an improved design so the patient can pull the product or service when they want it.
  • a process that meets your patient’s value expectations:
    • Quality – no defects.
    • Reliable delivery – right time, right product.
    • Rapid response to changing needs.

Once the future state VSM is drafted, planning commences for the implementation work. Planning and discipline are required for success with reaching the future state. Examples of future state improvement targets:

  • Reduce the lead time for the patient’s experience.
  • Reduce the number of patients waiting.
  • Increase the percentage of patient touch-time by staff.
  • Increase capacity to provide service.
  • Decrease the area footprint.
  • Eliminate defects and mistake-proof the process.

The point of value stream mapping is not the maps, but to understand the flow of the patient through the healthcare experience to drive improvements. The map is a tool created from real-time direct observation and measurement of the actual process. The future state VSM shows the vision of the process without waits, stopping, batching, mistakes, or other waste 12 months into the future. Many lean practitioners see value stream mapping as the fundamental tool to identify waste, reduce process cycle times, and implement process improvement, all creating value for the patient, who is the focus of the process.

HallbergTina Hallberg, RN, is a highly experienced registered nurse and senior consultant at GE Healthcare Partners. Her leadership and managerial skills are coupled with 20 years of nursing experience in acute hospital settings, including transplant and flight trauma, long-term care, and clinic settings including the roles of Chief Nursing Officer, Director of Nursing, Case Mix Manager, Staff Development Coordinator, and Operations Supervisor. Tina maintains sensei-level expertise in the application of Kaizen methodology to healthcare. She obtained her training under the tutelage of Taichii Ohno’s protégés through multiple missions to Japan. She may be reached at