Figure 7.1 shows a consolidated value stream map for the medical center we have investigated throughout this book. In this value stream there are at least four loops, each with its own takt time:

1. The inpatient care (hospital) or “pacemaker” loop 2. The emergent care loop 3. The primary care loop 4. The emergency transportation loop

The circles drawn on the map help you see where you need to concentrate your improvement efforts. During implementation, each loop becomes a focal point for improvement activity.*

The crux of the value stream is the pacemaker loop, which establishes the flow of information between patients and the pacemaker process. The design and management of the pacemaker loop will affect the design and management of all the other loops in the system. Because the pacemaker loop is

normally found toward the end of the value stream, it provides the basic rhythm of production with which the independent rhythms of all other processes must be synchronized.