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BPMJ
26,3
786
Received 12 March 2019
Revised 2 April 2019
Accepted 2 April 2019
Business Process Management
Journal
Vol. 26 No. 3, 2020
pp. 786-797
© Emerald Publishing Limited
1463-7154
DOI 10.1108/BPMJ-03-2019-0109
Process improvement in a
radiology department
Hatice Camgoz-Akdag and Tuğçe Beldek
Department of Management Engineering,
Istanbul Technical University, Istanbul, Turkey
Abstract
Purpose – The purpose of this paper is to improve the mammography and ultrasound screening processes to
increase the healthcare system quality and patients’ pleasantness while decreasing costs.
Design/methodology/approach – The data storage system is very insufficient so that data are collected
from hospital staff and by personal observations. A lean management tool, value stream mapping is used to
see the general view of the radiology department with its problems at a glance. Data and the map are used as
a guide to conduct a quality house to make a prioritization between the problems, to decide which one to solve
first, of patients at the hospital.
Findings – Problems of the radiology department related to mammography and ultrasound and suggestions
to these problems according to the quality house conducted.
Originality/value – The paper consequently focuses on the value creation process and on how to revisit
managing for quality in the systems perspective.
Keywords Quality function deployment, Value stream mapping, Process improvement,
Lean management, Healthcare systems
Paper type Research paper
Introduction
Today quality definition is totally turned out to satisfy customers on time. This goal can
be reached by some calculations in a production line but it is more difficult for a service
sector. Especially in healthcare systems, it is more important to give a high-quality service
to the patients. When the human life is considered, it is vital to start the treatment quickly.
Waiting is the biggest problem at a hospital, which increases the risk of exacerbation of
the disease. Even at the beginning of the healthcare system, patients try to get an
appointment from the hospital and they wait for long time periods, sometimes for months,
to see the doctor.
These kind of delays leads to the integration of lean management and healthcare
systems. Lean management aims to eliminate actions which do not add any value to the
process that are defined as “waste.” Elimination of non-value added steps, shortens the
lead time of the process which means to reach customer more quickly. The current state of
the hospitals’ departments can be provided by some lean management tools. With the help
of the value stream mapping (VSM), the big picture of a whole process can be seen.
This picture shows every step that the patient will follow and it also tells about the cycle
time for each service. If any of the service steps are not necessary, it is tried to be
eliminated such as walking between too many doors, waiting for the reports, waiting for
registration, etc.
Non-value added activities’ elimination is not the only thing that should be considered.
Patients’ satisfaction is also important and it should be checked if they want anything
according to the system and the hospital as a building. The way to convert customers’ needs
to real developments is to use “House of Quality” (HOQ) which is a tool for quality function
deployment (QFD). Voice of customer leads to technical properties of the thing that can be
either a product or a service, and new product/service development will be the result.
The needs of patients’ are very important to draw the future state map of the hospital’s
department. Both current state map and HOQ will help to conduct future state map of the
value stream. In this study, data are taken from the paper which gives details about the Radiology
radiology department’s current situation at Şişli Hamidiye Etfal Hospital in Istanbul, department
Turkey (Camgöz-Akdağ et al., 2017). The radiology department is considered with its
mammography and ultrasound units. The purpose of this paper is to improve the
mammography and ultrasound screening processes to increase the healthcare system
quality and patients’ pleasantness while decreasing costs.
After the introduction part, lean management and lean in healthcare topics will be 787
covered under literature review. In the third part, methodology will be explained and then
current state of the radiology department will be mentioned. HOQ will be studied at the fifth
part and finally a future state map will be shown before the conclusion part.

Literature review
Lean management
Lean manufacturing, which is also called the “Toyota Production System (TPS)” was a new
process-driven production system for the industry, founded by Japanese leaders
(Abdulmalek and Rajgopal, 2007). The main aim of lean manufacturing is to get rid of
the “waste” while increasing the quality of the product (Sundar et al., 2014). Waste types can
be classified in eight different ways: producing more than the need, inventory, defects,
waiting, transportation, extra motions, non-value added activities and the unused human
ability. These waste cost nearly 95 percent of the whole production cost which is mentioned
by Taiichi Ohno who is one of the leaders of TPS (Kilpatrick, 2003). Main action of TPS is to
eliminate different types of waste, such as defective products, inventory, transportation,
waiting, movement and overproduction (Ohno, 1988).
Lean principles mainly aim to make a sustainable production line while eliminating non-
value added activities. This line has to work with customer orders which mean a pull system
(Sundar et al., 2014).
In August 1997, a non-profit organization “Lean Enterprise Institute, Inc.” was founded
by James P. Womack. He aimed to explain lean thinking in accordance with the Toyota
system which is being used by many different sectors spread wide (Lean Enterprise
Institiute, 2000). The Lean Enterprise Institute website gives detailed information about lean
principles which is summarized in Figure 1.

2. Map
1. Identify
the Value
Value
Stream

5. Seek 3. Create
Perfection Flow

4.
Establish
Pull
Figure 1.
Source: www.lean.org/WhatsLean/Principles.cfm Lean principles
(accessed March 5, 2018)
BPMJ Not only in manufacturing but also service industry uses lean principles in spite of
26,3 application of mentioned ones are certainly different. The difference is that many service
area works with pull system, which means the customers’ needs trigger the production of
the service. If the system has problems in terms of the process, then waiting periods will be
longer (Maleyeff, 2006).

788 Lean in healthcare

In a production line, lean manufacturing aims to create a high-quality product and an
on-time shipment to the customer. In Canada, these lean principles are concerned for
healthcare systems because of the excess patient amount (Ng et al., 2010). Recovery of the
patient is the total of the value created in the medical service. For this reason, as mentioned
for production line, also in healthcare sector, the process has to be customer based, that
means patient based at a hospital (Kujala et al., 2006).
In a healthcare system, to reach a “perfect” medical experience, delays, waiting times in
a queue, unnecessary repeating actions and false applications should be eliminated or at
least minimized. When lean principles are adapted to healthcare systems to create value,
some issues have to be considered such as patients, taxpayers and service providers’
equality and the legal issues for costing while reaching the required pleasant
level for patients. Even though every process in a production line is known by its
standards, in a service line especially at a hospital, patients’ road is not clear due to
different examination results. This uncertainty causes more complicated systems to be
analyzed (Young et al., 2004).
Waste definition differs from sector to sector so that when healthcare systems are
considered, mostly documentation causes “waste.” Also the whole process flows and the
hardware of the hospital can yield non-value added activities (Campbell, 2009).

Methodology
Value stream mapping
Implementing lean principles starts with the analysis of current situation to classify value
added and non-value added activities. VSM is one of the most efficient way to do this
classification. The map shows the whole process of the production or service line with
symbols. Its minimal structure is mainly related to “lean thinking.” The process drawn in
the value stream map starts from the beginning that raw materials come from suppliers, and
ends at the shipping department. The expert which draws the map, follows both the
production steps and information flow at a random time and captures that moment.
This map is called “current state map” (Gahagan, 2007).
Current state map shows the bottlenecks on a one picture. With lean principles, these
problems which are classified as non-value added activities, should be eliminated or
improved. After eliminating those “waste” improvement areas are shown in “future state
map” (Rahani and Al-Ashraf, 2012).
One of the key applications of lean management is VSM. It helps to identify each process
step at an organization. This map makes all actors at the supply chain, to understand the
production or service process line and with the elimination of non-value added activities to
improve it. Workers from different actors should come together to study on VSM to improve
the process via lean thinking. VSM should be very detailed to show every kind of non-value
added activities to make a big change in the whole picture. These small activities have to be
decided if they add any value to the patient in a hospital process or not. If the activity
creates a value then it should remain in the process flow. After current state analysis, future
maps are drawn to see the improvement and this step should be repeated to reach ideal state
(Gellad and Day, 2016).
 VSM is being used in different areas also for healthcare systems. Hoffmann studied HIV Radiology
services to observe medical processing time for each step in South Africa (Hoffmann et al., department
2018). Ramaswamy studied at Kenya, for quality improvement of a healthcare system with
the light of lean principles and VSM (Ramaswamy et al., 2017).

Quality function deployment

New product or process development relies on meeting customer requirements and this 789
conversion can be done by “Quality Function Deployment (QFD)” (Summers, 2010). The
main aim of QFD was to understand the need of the customer to develop new products.
For this reason, the analysis of customer demand, product development and management of
quality constitute the main structure of QFD. Many different areas are also included to QFD
such as decision-making, costing, engineering, etc. QFD has no strict boundaries when the
application is considered (Chan and Wu, 2002). Figure 2 shows a flowchart of QFD steps
(Bolar et al., 2017).
One of the tools of QFD is HOQ that helps to convert customer requirements to technical
properties. The voice of customer is the main source of HoQ that it collects and analyses. It is
primary to understand customer needs for quality function deployment which can be
explained by the following steps:
• defining customer needs for their satisfaction;
• finding out the importance weights of these needs between each other; and
• comparing related companies according to these customer needs (Garver, 2012).
QFD is being used at different sectors with the aim of improving quality. Buttigieg studied
at a Maltese hospital to develop medical service at accident and emergency. He combined
QFD and logical framework approach for healthcare system improvement. This approach

Customer
(Infrastructure WHATs HOWs
User) Input

WHAT-1 HOW-1
Prioritize

Correlation

WHAT-n HOW-n

Relationship Absolute
Weights

Ranking
Figure 2.
Steps of QFD
Source: Bolar et al. (2017)
BPMJ was applied to the Maltese hospital to validate its efficiency (Buttigieg et al., 2016). Another
26,3 study used QFD to convert residents’ needs to technical properties to improve municipality
works at a Swedish urban community (Kullberg et al., 2013).

Current state of the radiology department

There are two mammography devices at the radiology department of the hospital but one of
790 them is not in use. Also the mammography room closes its doors less than six hours as
working time. For ultrasound process, there are four radiologists and one assistant but they
are not only checking for breast cancer but also some other diseases. This hospital evaluates
nearly 550 patients in average per month via mammography. There are wrong treatment
results at the hospital such as recalls or making unnecessary tests. The whole process starts
with the polyclinic examination. The doctor will refer to mammography and the patient will
get an appointment. Mammography appointment may be a few days later and when the
patient comes, she has to wait in a queue. After mammography screening the patient has to
wait for the report to see her doctor again. If the doctor decides for another test then an
ultrasound process will start (Camgöz-Akdağ et al., 2017).
The current state of the radiology department of Şişli Etfal Hospital is visualized by the
value stream map. This method captures a random moment to see the value added and
non-value added activities on a single picture. The current state value stream map is given
in Figure 3.
The timeline shows both value added and non-value added activities’ durations. Bottom
lines between processes show non-value added activities, mostly waiting activity for the
patient. The biggest bottleneck is waiting for the mammography appointment date, the
report and the ultrasound appointment date. These durations are close to each other which
are three to four days on average.
The value-added activities are only presents the steps to get the result from the doctor in
the end. This time is totally 67.3 min, nearly 1 h. But the whole process continues totally for
17367.95 min, nearly 12 days. This big difference is caused by the “waste” which decreases
patients’ satisfaction. The HOQ will help to understand which problem to focus and improve
first. Cycle times of the related processes can be seen in detail in Table I.

House of quality
According to the aim non-value added processes, which extends lead time unnecessarily,
have to be eliminated or minimized. HOQ will help to understand customer needs
and prefer which area to improve primarily. The reference signs of HOQ are defined
at Figure 4.
With the help of experts in their study area, doctors, personnel, academicians, has
decided the correlation weight between different customer needs and improvement area.
At the end the priority is clearly occurred by the HoQ calculations. The HoQ is given in
Figure 5. This HoQ shows patient requirements and relations between technical properties
of the radiology department and relative weights of these relationships. As a technical
property, cabinets are strongly related to the examination moment and the privacy of the
patient. A new digital mammography device is strongly in relation with the patient needs
of taking the service on time and relying to the test. Another very important technical
property is radiologist’s experience that effects nearly every patient requirement.
The experience and training are very important to do the screening process in a quickly
and truly manner. Percentage of a technical requirement weight is represented
by the relative weight score, which is the rate of importance weight to the total weight
(Camgöz-Akdağ et al., 2016).
The calculations show different levels of relative weight, which are related to the
technical requirement. Technical requirement is defined according to customer needs. The
 Radiology
department at the Patient
hospital

Registration Examination Mammography Registration Intern Preparation Test Dressing up Report Report Doctor Medication Ultrasound Registration Registration Test Doctor
desk desk desk result date desk desk

Cycle Time CT: 5.1 min CT: 3 min CT: 2.5 min CT: 0.7 min CT: 4 min CT: 7 min CT: 3 min CT: 7 min CT: 5 min CT: 3 min CT: 3 min CT: 5 min CT: 2 min CT: 3.5 min CT: 8 min CT: 5 min
(CT): 0.5 min

0.5 min 5.1 min 3 min 2.5 min 0.7 min 4 min 7 min 3 min 7 min 5 min 3 min 3 min 5 min 2 min 3.5 min 8 min 5 min

2 min 2 min 5,760 min 3 min 1.2 min 1 min 1 min 0.25 min 5,760 min 2 min 2 min 5,760 min 3 min 1.2 min 1 min 1 min
department
Radiology

791

Figure 3.
Current state map
BPMJ Process name Cycle time (minutes)
26,3
Registration desk 0.5
Examination 5.1
Mammography desk 3.0
Registration desk 2.5
Intern 0.7
792 Preparation 4.0
Test 7.0
Dressing up 3.0
Report 7.0
Report result 5.0
Doctor 3.0
Medication 3.0
Table I. Ultrasound date 5.0
Cycle times of the Registration desk 2.0
radiology department Registration desk 3.5
process steps in the Test 8.0
current state Doctor 5.0

Legend

Strong Relationship 9

Moderate Relationship 3

Work Relationship 1

Strong Positive Correlation

Positive Correlation

Negative Correlation

Strong Negative Correlation

Objective is To Minimize
Figure 4. Objective is To Maximize
House of quality-sign
descriptions Objective is To Hit Target

results of the HoQ give priority to “Radiologist Experience” with 13.4 relative weight. Then,
the second more important subject is “Appointment Duration,” which is a big problem for
patients to wait for a long time even the illness continues. Also this problem is clear in the
current state map.
It can be said that training is more important than other factors as seen from HoQ.
The technical side of reporting comes after which can be defined as “instant reporting.” The
manual reporting, doctor dictates to a nurse, takes so much time that the patient is not able
to get the report on the same day. New dictation technologies may be considered to use at
the radiology department.
Another important factor is “Database.” Lack of database causes missing information
about the patient, and this situation causes duplication of tests or false measurements.
These problems will be considered for future improvement at the radiology department.
 Radiology
++ ++ department
++
++ +
++ ++
+ ++ + + ++
–– ++ ++ ++ 793
+ –– –– ++
++ ++ ++ –– ++ ++ +
Column no. 1 2 3 4 5 6 7 8 9 10
Direction of Improvement:
Minimize (▼), Maximize (▲) or Target (x)

Quality

New Digital Mammography Device

Characteristics
(a.k.a. “Functional
Max Relationship Value in Row

Requirements” or

Technical Personnel Training

“Hows”)

Digital Screens for Queue

Radiologyst Experience
True Test Requirement
Appointment Duration
Weight/Importance

Instant Reporting
Relative Weight

Demanded Quality

Database
Cabinets

Hygiene
Row no.

(a.k.a. “Customer
Requirements” or
“Whats”)

1 9 5, 6 2, 0 Guidance

2 9 2, 8 1, 0 Registration Moment

3 9 11, 1 4, 0 Examination moment

4 9 16, 7 6, 0 Service on Time

5 9 13, 9 5, 0 Technician Attitude

6 9 8, 3 3, 0 Radiologyst Attitude

7 9 19, 4 7, 0 Reliable Testing

8 9 22, 2 8, 0 Privacy in changing and examination room

Target or Limit Value

Difficulty
(0 = Easy to Accomplish, 10 = Extremely Difficult)
Figure 5.
Max Relationship Value in Column 9 9 9 9 9 9 9 9 9 9 House of
Weight/Importance 438, 9 516, 7 655, 6 300, 0 688, 9 566, 7 455, 6 522, 2 366, 7 700, 0 quality (HoQ)
Relative Weight 8, 4 9, 9 12, 6 5, 8 13, 2 10, 9 8, 7 10, 0 7, 0 13, 4

Future map of the radiology department

Improvement areas are shown in future map (Figure 6). As it is seen, total lead time of the
patients’ road, which starts from the beginning of the radiology department and ends after
the doctors’ reporting, decreased nearly 9 days which means a big improvement. As it is
seen from the future map, preparation, test, dressing up, report and report result process
cycle times are decreased by some technological and physical changes in the hospital. Cycle
times of the radiology department process steps in the future map are given in Table II.
With more than one dressing room, patients will not have to wait for other patients to
enter the mammography room. Another improvement area is technologically developed
computers and systems. With the simultaneous voice transformers doctor can dictate the
result and the nurse can directly take out the report. After the improvement, maximum one
day later, the report can be delivered to the patient. Waiting a mammography result is
 26,3

794
BPMJ

Figure 6.
Future state map
Radiology
department at the Patient
hospital

Doctor Medication Ultrasound Registration Registration Test Doctor

Registration Examination Mammography Registration Preparation Test Dressing up Report Report
date desk desk
desk desk desk result

Cycle Time CT: 5.1 min CT: 3 min CT: 2.5 min CT: 2 min CT: 6 min CT: 2 min CT: 5 min CT: 2 min CT: 3 min CT: 3 min CT: 5 min CT: 2 min CT: 3.5 min CT: 8 min CT: 5 min
(CT): 0.5 min

0.5 min 5.1 min 3 min 2.5 min 2 min 6 min 2 min 5 min 2 min 3 min 3 min 5 min 2 min 3.5 min 8 min 5 min

2 min 2 min 1,440 min 4 min 0.25 min 1,440 min 2 min 2 min 1.2 min 1 min 1 min
1,440 min 3 min
Process name Cycle time (minutes)
Radiology
department
Registration desk 0.5
Examination 5.1
Mammography desk 3.0
Registration desk 2.5
Preparation 2.0
Test 6.0 795
Dressing up 2.0
Report 5.0
Report result 2.0
Doctor 3.0
Medication 3.0
Ultrasound date 5.0 Table II.
Registration desk 2.0 Cycle times of the
Registration desk 3.5 radiology department
Test 8.0 process steps in the
Doctor 5.0 future map

nearly 4 days at the current situation that means extending the treatment process. With the
correct arrangement of appointments and the required test plan, patients will come on
time and will not wait for long queues. In front of the mammography and ultrasound rooms
there may be electronic screens to show the coming appointment. This will also improve
satisfaction at a less crowded hospital isle.

Conclusion and recommendation

To conclude, the problematic area can be found both from current value stream map and
HOQ. The aim is to see the primary subjects that can be improved at the radiology
department. While decreasing cost and waiting times, the patient satisfaction and
healthcare system quality increases.
The fastest way to eliminate non-value added activities, is to find out the unnecessary
waiting steps. Waiting, starts from the appointment step, even out of the hospital and
continues in front of the mammography or ultrasound department doors. New technology
will help to organize appointment durations and saving patient information. Another
system can be used at reporting step so that patients can get their results quickly.
Another very important issue is training. Healthcare personnel must know the whole
radiology process that they are responsible of. With lack of knowledge, missing tests,
duplications or false results can be seen. The doctor has to determine the right test type due
to the patients’ symptoms. After the test request the radiology technicians have to make the
correct measurement.
Due to these small changes the whole process will be finished nearly 4 days earlier. If
more database can be saved at the radiology department, there may be more detailed data
analysis so that different solutions can be added to increase the system quality.

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About the authors

Hatice Camgoz-Akdag received the PhD Degree on the field of quality from Brunel University, UK, the
MBA Degree from Eastern Mediterranean University, Turkish Republic of Northern Cyprus, and the
BA Degree from Bosphorus University, Turkey. Hatice Camgoz-Akdag is Associate Professor at
Istanbul Technical University, teaching Production Planning and Control, Quality for Engineers, Radiology
Fundamental Topics of Production Management, Quality Standards and Certification and Total department
Quality Management courses. She is currently working with lean healthcare applications, value-added
activities, especially doing projects on how to improve breast cancer departments patient flow. She has
a number of publications on the subject of quality, six sigma and benchmarking and two best paper
awards from international conferences. Hatice Camgoz-Akdag is the corresponding author and can be
contacted at: haticeakdag2002@yahoo.com
Tuğçe Beldek is PhD Student at Management Engineering Department, Istanbul Technical 797
University, Turkey, and the MSc Degree from Management Engineering Department, Istanbul
Technical University. She is currently researching the topics healthcare management, artificial
intelligence in healthcare, green hospital and lean in healthcare.

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