Drs$.$ Pat and Pam Schmidt started the Westerville Phy$-$sician Practice in Westerville, Ohio, in $2000$ to provide primary care services to the community. There was not much development in Westerville at that time; how$-$ever, the couple started the clinic anticipating future growth. Competition was weak and they ran the clinic by themselves with a nurse and receptionist. Eventu$-$ally, Westerville had a burst of growth and development with more and more people moving to this suburb of Columbus, Ohio. There were more patients to see and more clinics popped up$.$ Patients had more choices to get primary care. Patients chose the clinics where they were seen quickly. The Schmidts hired some more doctors, and Medical Assistants $($MAs$)$ to meet the increasing demand. It helped for a while but eventually they started losing their customers to their main competition a few blocks away$$The Westerville Fast$-$track Physician Prac$-$tice. By $2015$ the revenues were down by $40$ percent. Informally collected patient satisfaction scores related to wait times were down from $86$ percent to an abysmal low of $54$ percent. Doing business the old way was not going to help. The Schmidts had to rethink a new strat$-$egy to continue supporting the growing community and not lose their patients to the competition. They thought of building a bigger clinic and hiring more doctors. Pat Schmidt was quite active on LinkedIn. Pat came across a link on Dr$.$ Deb Louis$$s profile$$Physician prac$-$tices successfully implementing lean to retain patients and increase revenues.$$ Pat Schmidt had recently added Deb as a connection. Deb Louis was a primary are physician in her previous career. She successfully applied lean to her own practice and eventually sold it off at a great profit. She started a lean consulting com$-$pany in Columbus, Ohio, where she worked full time. Pat Schmidt read the article that came with the link and shared it with Pam. Intrigued and curious to learn more, the Schmidts decided to meet with Deb Louis. Deb agreed. $$Let$$s meet at the gemba,$$ she said. $$Meet where?$$ The Schmidts were confused. $$Gemba is the place where the actual work happens. So$,$ let$$s meet at your clinic. That$$s where we can get all the information, the basis for improvement,$$ she explained. Deb arrived at the clinic at $10$ a$.$m$.,$ the next Monday. The Schmidts met her in the lobby. Deb noticed there were many patients in the waiting area. It was hard to differen$-$tiate which patients were waiting to get registered and which ones were registered and waiting to see the doctor. $$We think we should expand our existing clinic to accommodate the new demand,$$ the Schmidts men$-$tioned. Deb smiled. She knew that most people try to jump to solutions $($most of them irrelevant$)$ before really understanding the problem. $$Let$$s talk about the prob$-$lem first. What is it that you are trying to solve?$$ Pat said, $$Well as you can see, there are $11$ patients waiting here in this big waiting area; $6$ waiting to get registered and $5$ are waiting to be seen by the doc$-$tor. If we build more exam rooms and hire some more doctors, we can see these patients quicker and they won$$t have to wait.$$

$$But what is the problem?$$What do you mean!? We just explained it$.$ The Schmidts were a bit annoyed. Deb said, $$Try one more time and explain the prob$-$lem. Why did you want to meet me$?$ What were your concerns?$$Well$,$ we are losing our patients to competition. Our patients are waiting too long to see the doctor. When we looked at our patient customer satisfaction survey results, our patients were highly dissatisfied with the amount of time they had to wait to see the doctor.$$Do you have any metrics?$$Well$,$ the patient satisfaction has gone down from $86$ percent to $54$ percent and our revenues have gone

down by $40$ percent as well.$$Aha$!$ Did you ever measure how long it takes for a patient right from arrival till when they leave the clinic?$$ Pat and Pam looked at each other, and both said at the same time, $$No$.$ Why would we do that?$$Well$,$ then how do you know that your patients are

waiting too long? How much is $$too$$ long?$$ The Schmidts felt a bit embarrassed. $$Well$,$ let me tell you about a tool we use in process improvement$$the Value Stream Map. It is a visual rep$-$resentation of the process. It shows the flow of people, information and materials and the amount of time spent on parts of the process and some other metrics. The key is to understand the process first.$$ The Schmidts were listening intently. $$Do you have a stopwatch on your cellphone?$$ Pam took out the smartphone and pulled up the stopwatch. $$Now what we will do is observe the process in your clinic and time it as we go$.$ The patient flow is shown in Exhibit $1.$

A patient just stepped inside. $$Let$$s follow this

patient,$$Deb said quickly.$$ The Schmidts were unsure but they decided to follow Deb$$s directions. $$Start your stop watch and press lap every time the patient goes to the next milestone in the process.$$ The patient enters the lobby and looks ar