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“The Blue Yarn” – Transforming Healthcare in Pursuit of the Perfect Patient Experience

How a thread of blue yarn helped healthcare designers shift the paradigm in patient care design. Our EDAC team’s Evidence-Based Design (EBD) Hot Topics virtual session challenged Parkin colleagues across our three offices to explore creative ideas about designing for improved patient experience, Lean design, and continuous process improvement.

Parkin’s EDAC team recently delivered a Hot Topics presentation on The Blue Yarn, a case study about how, at the turn of the millennium, Virginia Mason Medical Center implemented a new, Lean, operational model based on the Toyota Production System.

The team then challenged Parkin colleagues to discuss what they learned and how they could apply those lessons to our projects and clients across Parkin project sectors. The session fostered creative ideas through five virtual break-out rooms, where teams ideated about improvements to patient process mapping, advancement of waiting room design, and development of separate departmental entrances to reduce the steps patients must travel to arrive at their points-of-care destinations.

What is “The Blue Yarn”?

In the late 1990s, Virginia Mason Medical Center CEO, Dr. Gary Kaplan, needed to find a way to cut costs. He decided to explore an unorthodox solution. Wondering whether Japanese automobile production efficiency could be translated to his hospital’s operations, he looked to the Toyota Production System (TPS) for inspiration. Kaplan ultimately invited a TPS “sensei” to work with his hospital team who, after a tour of the facility, noted excess muda, a TPS term that translates roughly as ‘waste’ in English.

To demonstrate the amount of ‘waste’ patients were experiencing in the hospital, the sensei invited the care team to mark patients’ journeys through the facility using a thread of blue yarn on a map of the centre. The result was visually impactful—the blue yarn was a tangled mess! Patients were travelling long distances, and waiting at every stop.

“When we looked at it, we were amazed at how far patients travelled. We were asking oncology patients, whose oxygen-carrying capacity is compromised because the chemotherapy destroys a lot of red blood cells so that makes them short of breath, and here we are asking patients to do this who are short of breath to begin with. So it was appalling to us,” explains Michelle Wettland in an interview on “The Blue Yarn” episode of the 99% Invisible podcast.

What had started out as a cost-cutting exercise quickly morphed into a patient-centred design process. The resulting design solutions ended up providing better patient experiences and Lean operational improvements while also lowering costs. Today, the Virginia Mason Production System (VMPS) has been adopted by many other hospitals, and the Center has received numerous awards in recognition of excellent patient care and safety.

Applying the Toyota Production System to the patient experience

The Our Hot Topics breakout groups returned to the main session with various insights about how The Blue Yarn approach could impact our design practice. One group considered how waiting room spaces represent a direct correlation with whether a hospital’s operational model is successful or failing in the eyes of patient-centered care and efficiency. This led  the group to explore how TPS waiting room design can be integrated into a patient’s journey through a healthcare facility.

Patients often cannot congregate in large waiting rooms due to varying immuno-compromised diagnoses, or they may not have the strength to be travelling all around the hospital in an inefficient patient-care path to receive various treatments. Also, through the COVID-19 pandemic, we learned that being socially and physically distanced along the patient journey is key to curbing the spread of disease.

The result is that smaller waiting rooms are needed along with sub-waiting spaces placed along the patient’s journey. That journey needs to follow a one-way flow that reduces circling back to previous therapy spaces, which can be achieved by implementing a pathway system similar to those used in Ikea stores around the world. In this model, patient short-cuts can be included in the system to shorten patient travel distance from point A to B, minimizing the amount of “blue yarn” needed for the patient journey.

TPS in Waiting Room design

In TPS, waiting is a form of waste, but waiting rooms in healthcare are a necessity and our breakout group agreed that they do not need to be eliminated. They can be designed, however, to achieve several desirable outcomes—providing patient comfort through positive distractions, opportunities for education, and reducing anxiety—by being placed along the exterior with views to nature and natural light.

Elements like flooring can achieve triple duty as wayfinding signals by using colours that are associated with specific departments. Flooring material should also help reduce the risk of slips and falls and stress on joints. The material used can also deliver comfort and patient satisfaction by offering a natural, rather than institutional, feel. Similarly, furnishings and other fixtures can contribute to patient satisfaction and comfort.

Waiting spaces themselves need to be designed with appreciation for users’ needs. In some cases, clear, wide, turn-spaces and wide corridors may be necessary. In others, quiet, low-traffic spaces may be more appropriate. Easily movable or modular furniture can provide flexibility for changing needs. Toilet and sink facilities that accommodate various levels of accessibility and fixtures like fold-down grab bars that improve patient safety contribute to improved patient satisfaction.

Patient comfort and satisfaction can be delivered by providing positive or meaningful distractions such as views to nature, artwork, televisions, and providing access to the Internet. Positive distractions can include patient education, such as nutritional tutorials, and patient care information on display boards in sub-wait areas.

Airport-style hospital design

One of the more controversial design decisions made at Virginia Mason Medical Center, 20 years ago, was to tailor the facility design to the patient experience. This meant reorienting therapy spaces and staff offices into the interior and putting patients at the outer edges of the facility where they have access to natural views through large windows.

Airport-style hospital design provides a series of drop-off entrances, ensuring that there are no more than 20 paces to a particular department entrance. This ensures that the patient journey is as efficient and easy to navigate as possible from the parking lot to the department intake, and into the therapy process.


The overarching goal of TPS is to develop a design equilibrium that is flexible, smooth, and lean. One of its main tenets is to constantly be searching for improvement of existing systems. When used as a guide in healthcare facility design, along with the principles of Evidence-Based Design, TPS encourages architects and designers to continue to deliver improved healthcare spaces that provide a positive impact on the overall patient experience.

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