What queues reveal about healthcare management
Crowded waiting rooms, occupied hallways and patients who spend months seeking an appointment, a test or surgery expose one of the most persistent difficulties in Brazilian health care. Waiting has become one of the most visible signs of the problems faced both by the Unified Health System (SUS) and by the private network.
For the patient, the time that elapses between the identification of a need and the start of care can mean clinical deterioration, insecurity and suffering. For professionals, the accumulation of people waiting for care increases pressure, multiplies interruptions and makes it harder to set priorities. For organizations, queues reveal difficulties in coordinating demand, capacity and flow.
The data help to gauge the size of the problem. A survey by Instituto Locomotiva carried out in November 2024 with 1,500 Brazilians from class C, in 127 municipalities, showed that 60% of respondents considered the wait for appointments with specialists in the SUS to be very long. Another 56% made the same assessment about tests and 46% about appointments with general practitioners. Among the participants, 24% reported a worsening of their health associated with the delay and 94% stated that waiting time can put lives at risk.
Another survey, released in April 2025 by Vital Strategies and Umane, found that 62.3% of the people who needed primary care during the previous 12 months did not even seek it. Among those who sought help and were unable to get care, 62.1% cited the delay as one of the main obstacles.
In serious diseases, each additional period of waiting carries even more weight. A survey released in 2025 by the Movimento Todos Juntos Contra o Câncer found an average of 50 days until a cancer diagnosis was confirmed and of 75 days between diagnosis and the start of treatment in the SUS. Both periods exceed the legal deadlines of up to 30 days for performing the tests needed to clarify the diagnosis and of up to 60 days for starting therapy. The longest delays were identified in the North and Northeast regions.
Different queues, distinct problems
The word queue covers quite distinct situations in the health system. There is the wait for an appointment in primary care, the delay in accessing a specialist, the time that elapses until a test is performed, the stay inside the emergency room and the wait for hospital admissions, surgeries or more complex treatments.
Each of these queues forms through different mechanisms. Some arise within a single unit, in the connections between reception, triage, consultation, diagnosis and discharge. Others cut across municipalities, hospitals, laboratories, regulation centers and specialized services. There are also situations in which installed capacity is insufficient for the demand or is unevenly distributed among regions.
Understanding where waiting forms is the first step in tackling it. A queue can be born long before the patient enters the hospital. It can also remain invisible for weeks in a referral list, appear in a specialist's schedule or build up between clinical discharge and the patient's actual departure.
That is why the crowded hallway is usually the final manifestation of problems produced in different parts of the system. The emergency room receives people who were unable to get timely access to primary care, absorbs delays in diagnosis and remains congested when beds are lacking or discharges do not happen at the expected time. The pressure observed in one area may originate in another.
The equation between demand, capacity and variability
The most immediate responses to a queue tend to focus on expanding capacity. Professionals are hired, rooms are opened, equipment is bought and task forces are created. These investments may be necessary, especially when there is a structural shortage of resources or an accumulated demand that clearly exceeds the available capacity.
Expanding capacity has little effect when it is not accompanied by changes in the way the steps connect. A new room, an additional piece of equipment or more appointment slots can increase supply at one step and, at the same time, overload the next one. The queue shrinks at one point and reappears further on because the system's constraint remains.
For this reason, flow management needs to consider the relationship between demand, capacity and variability.
Demand involves how many patients need care, at what times they arrive, through which channels they enter the system and what types of need they present. Part of it is predictable, such as elective appointments and procedures. Another part, especially in emergencies, varies significantly and requires flexibility.
Capacity also needs to be observed end to end. The constraint may lie in the availability of physicians, nursing professionals or equipment, as well as in the analysis of a test, the cleaning of a room, the preparation of a medication, internal transport, discharge paperwork or care after leaving the hospital.
Variability completes this equation. Patients with the same diagnosis may require different times and resources. Emergencies compete with scheduled procedures. Absences, delays and clinical changes affect planning. When each area seeks to optimize only its own performance, the system tends to accumulate patients waiting between the steps of care.
The queue comes to absorb the mismatch between demand and capacity. When an area receives more patients than it can serve, waiting prevents the overload from advancing immediately, but transfers the cost of this imbalance to the patient. Reducing a queue without correcting its causes may simply shift it to another point in the journey.
Making the flow visible
Lean management proposes a change in the unit of analysis. Attention stops focusing on the isolated performance of each area or department and turns to the path taken by the patient.
Value Stream Mapping (VSM) helps to represent this journey and to understand how patients, information, decisions and resources move through the system. The beginning and end of the flow depend on the problem being investigated. In elective surgery, for example, it may begin with the referral made by primary care and continue through the specialist consultation, pre-operative tests, authorization, scheduling, admission, procedure, recovery, discharge and subsequent follow-up.
This view makes it possible to measure the total time and distinguish it from the time actually devoted to care. A patient may receive a few hours of clinical activity over a journey that lasts weeks or months. The rest is spread among schedules, authorizations, waits for information, repeated tests, incomplete referrals and unavailability of the next step.
Mapping also helps to identify where decisions are made, what information arrives incomplete and who follows the patient when he or she moves from one organization to another. Many queues grow at the interfaces, spaces in which each area performs its task, but no one sees or takes ownership of the continuity of the journey as a whole.
This understanding prevents the problem from being attributed generically to lack of attention, poor communication or excess demand. The investigation looks for more specific mechanisms. It may reveal, for example, that discharges are concentrated in the late afternoon, that tests requested in the morning are analyzed only the next day, or that different specialties reserve the same resources at coinciding times.
Stability to deal with variability
After understanding the flow, teams can test changes and learn from their effects. Standardized work plays an important role in this dynamic because it establishes the best known way to carry out recurring activities safely, clearly and with the participation of those who do the work.
In health care, standardizing means defining essential criteria, sequences, responsibilities and information. The standard preserves clinical judgment and reduces variations that have no clinical justification. Handoffs between teams, room preparation, test sample collection, medication administration and discharge processes become more reliable when people share a common reference.
Standards also make deviations visible. When a discharge scheduled for the morning does not happen, the team can identify the obstacle: a pending test, an incomplete prescription, waiting for transport, an additional assessment or a lack of support for continuity of care.
Daily Management (DM) creates a routine to monitor these deviations. Brief meetings at the workplace make it possible to review the patients' situation, anticipate risks, adjust priorities and quickly call on those who can contribute to the solution. The goal is to prevent small interruptions from silently accumulating and causing a major congestion at the end of the day.
Visual management supports this process by making the actual state of performance accessible to everyone. Beds expected to be vacated by discharge, pending tests, patients awaiting transfer and capacity constraints can be monitored in a shared way. Information no longer remains scattered across systems, spreadsheets and individual conversations.
Workplace organization and efficient replenishment systems also reduce interruptions. Professionals who are searching for materials, medications or equipment temporarily stop caring for the patient. 5S and kanban can support the availability of the necessary resources at the point of use, in the right quantities and with clear replenishment criteria.
Bed management requires another type of coordination. Releasing a bed depends on clinical discharge, paperwork, patient instructions, transport, cleaning and preparation for the next occupant. Each activity has its own owners and times. Improvement comes when they are planned and carried out as parts of a single flow, with clear responsibilities and coordination between steps.
Reducing peaks created by the system itself
Some queues result from the way the flow of the entire system is (or is not) connected. Appointments booked for the same time, patients called in large batches and elective procedures concentrated on certain days generate artificial peaks in demand. In other periods, professionals, rooms and equipment remain underused.
Lean management seeks to better distribute the predictable load and synchronize it with the capacity of the subsequent steps. Scheduling a surgery, for example, needs to take into account the availability of the operating room, post-anesthesia recovery, beds, tests and support teams. The productivity of a single area is of little value when its increase congests the rest of the system.
Urgent demand requires another type of response. It can hardly be leveled with the same precision as elective procedures. The system needs to develop flexibility, protect some capacity and establish criteria that allow it to respond to variations without abandoning the other patients.
Pull flow contributes to this coordination by preventing one area from sending more work than the next can absorb. In practice, this means controlling the number of patients being cared for simultaneously at each step, defining clear conditions for transfers and preparing the next step before moving them.
This logic reduces the number of patients stalled between activities. It also prevents each department from pursuing its maximum local occupancy while patients remain waiting for continuity of care.
From the unit to the network
Improving hospital flow runs into limits when the analysis ends at the institution's door. Many prolonged hospital stays depend on the existence of home care, rehabilitation, continuing care or follow-up in primary care. Likewise, many emergency visits could have been avoided through more timely access at other points in the network.
A systemic approach requires integrating access, regulation, diagnosis, treatment, discharge and continuity of care. This involves sharing information, aligning referral criteria and following the patient through the transitions between services.
It also requires recognizing the uneven distribution of resources. There are situations in which capacity is truly insufficient and needs to be expanded. Lean management helps to qualify this decision by showing where the constraint lies, what additional capacity is needed and what process changes should accompany it.
In this way, better management and investment no longer compete as explanations. Better processes make it possible to use existing resources more effectively and to direct expansion to the points where it will have the greatest impact on care.
Learning from the system
Reducing a queue represents the beginning of a learning process. The organization needs to check whether the total journey time has fallen, whether clinical risk has decreased and whether the workload has remained sustainable.
It also needs to observe where waiting has reappeared. An improvement at the entry point may increase congestion in diagnosis. A reduction in length of stay may transfer problems to families or to primary care. A task force may temporarily reduce waiting, but the queue will grow again as long as the causes that feed it remain active.
The lean perspective seeks to understand these consequences and to develop in teams the ability to solve problems day to day. Leaders close to the flow help to formulate questions, remove barriers between areas and sustain cycles of experimentation. Solutions emerge from the combination of clinical knowledge, the experience of professionals and an understanding of the system.
Indicators also need to reflect this view. Number of visits, room occupancy and the productivity of each department show only parts of reality. Time to diagnosis, the full duration of the journey, safety, continuity of care and patient experience better reveal the performance of the system.
Time as part of care
Waiting in health care has both a technical and a human dimension. A test performed after the moment it was needed may lose part of its value. A delayed discharge takes up a bed that someone else needs and keeps the patient exposed to the risks of hospitalization. An appointment that takes months prolongs doubts, symptoms and limitations that affect a person's whole life.
Reducing queues requires better coordination of resources, decisions and activities along the patient's journey. This involves adequate capacity, connected processes, reliable standards, daily management and continuous learning.
Every hour removed from an avoidable wait gives time back to the patient and allows professionals to focus their energy on what gives meaning to work in health care. Improving flow, in this context, means delivering care more safely, at the moment it can produce the greatest benefit.
