<p>Until 2016, very few works had investigated the use of the VSM. With this research, we will discover if the situation has changed in the last 3 years. In the lean manufacturing context, different techniques that help the continuous improvement process can be used (Marin-Garcia & Bonavia, 2011; Marin-Garcia & Carneiro, 2010; Marin-Garcia et al., 2012; Scott, 2001). One is the Value Stream Map (VSM) (Coetzee et al., 2016; Marin-Garcia & Mateo Martínez, 2013; Vidal-Carreras et al., 2015). This publication is a protocol (Marin-Garcia, 2015; Marin-Garcia, 2019) that aims to promote research transparency and replication. The concepts investigated in it are defined (VSM and health services sector), a research niche is justified, and the search and codification procedure of the systematic literature review is established. Although there are different versions of the VSM (Dinis-Carvalho et al., 2018; Hines & Rich, 1997; Shou et al., 2017), we will focus on that proposed by Rother and Shook (1998). The main peculiarity of the version by Rother and Shook (1998) is that it graphically shows the flow of information and the flow of materials in the same diagram (Lucherini & Rapaccini, 2017; Shou et al., 2017; Vidal-Carreras et al., 2015), which is necessary to complete a project, a product or a service (Bevilacqua et al., 2014; Lucherini & Rapaccini, 2017). It is also very intuitive and easy to understand, even by non-technical people (Lucherini & Rapaccini, 2017).</p><p>The VSM version that we have chosen is usually applied via standardized symbols (Lucherini & Rapaccini, 2017; Vidal-Carreras et al., 2015) following a 4-stage procedure (Rother & Shook, 1998; Shou et al., 2017): 1) select a product family (each VSM represents a family of sufficiently homogeneous products to represent the process); 2) draw the current VSM; 3) model the improved process by drawing the desirable future VSM; 4) implement actions to obtain a similar process to the future VSM. These four stages can be split into eight in other implementation versions (Tapping, 2007; Tapping et al., 2002; Tapping & Shuker, 2003). The above procedure allows value-added (VA) and nonvalue-added (NVA) activities and initiating actions to be identified to improve the proportion of VA versus NVA (Bevilacqua et al., 2014; Shou et al., 2017; Vidal-Carreras et al., 2015). Our goal is to include any healthcare level (primary care, secondary care - medical specialists, hospitals, referral centers for rare diseases, and geriatric or disability care). We wish to explore the use in organizations of any country worldwide whose ownership is public, private or a nonprofit foundation. We will focus on patient health services. We will not include the pharmaceutical industry or the operation of governmental or nongovernmental public health structures (e.g. ministries, the Red Cross or similar). Different literature reviews on the VSM have been published. Some focus on analyzing several sectors, predominantly manufacturing. Previous research seems to indicate that the VSM allows the transparency of the process to improve by making it much more understandable for the agents involved in it (Shou et al., 2017; Vidal-Carreras et al., 2015); reduce process times (lead times) (Shou et al., 2017) and inventories (Shou et al., 2017). However, these results come mostly from repetitive manufacturing contexts (linked to the automotive or consumer electronics sectors, or their auxiliary industries), and normally from Anglo-Saxon countries. There do not seem to be enough publications in order to generalize these results to all kinds of contexts. Some publications reveal that the barriers from using such tools can overcome facilitators in public service contexts (Marin-Garcia et al., 2018b).</p><p>Very few reviews have focused specifically on the VSM and the health services sector (Nowak et al., 2017; Vidal-Carreras et al., 2015). Both conclude that there is not enough material to provide evidence for and a conclusive answer to our research questions. The systematic review that we propose in this protocol intends to answer (in a future publication) the following questions: 1) what is the VSM research gap that applies to the health services sector that currently exists?; 2) is the VSM being used in hospitals or other health centers?; 3) what VSM version is common in health sector publications?; 4) collect examples of the VSM in hospitals/heath centers; 5) how was the VSM used in the hospitals/health centers that have applied it?; 6) what problems and/or difficulties have arisen while drawing the VSM or after drawing it? Different programs will be used for the bibliometric analysis (see details in Marin-Garcia and Alfalla-Luque (2019)). First, the R Bibliometrix package (Aria & Cuccurullo, 2017; Garfield, 2004; Wulff Barreiro, 2007) and also the suitability of SciMAT (Cobo et al., 2012; Santana & Lopez-Cabrales, 2019) to visualize thematic maps and strategic maps will be tested.</p>
Different Within-Host Viral Evolution Dynamics in Severely Immunosuppressed Cases with Persistent SARS-CoV-2
