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Getting down to essentials through a lean design process
By Scott Holmes, AIA, ACHA, LEED AP, and Dan Schowengerdt
Although the “lean” concept has its origins in manufacturing—most notably the Toyota
Production System—it has recently garnered the attention of health care leaders as well.
Driven by many factors, including the need to decrease the cost of care, reduce errors
and understand more deeply the expectations of consumers, many health care leaders
have incorporated lean methods in their quality improvement infrastructures.
Approaches vary from spot application to a “deep dive” organizational transformation.
Motivations are as varied as the approach, but often leaders recognize that processes
are deeply flawed with middle management roles skewed to firefighting and applying
Band-Aids rather than making fundamental improvements. Work processes have
frequently evolved, but less often have they been deliberately evaluated, understood
and overhauled to correspond to changes in technology and consumer expectations.
Recently, market forces have played a greater role in change. With the release of the
Institute of Medicine Report on errors in hospital care, numerous and broad initiatives
have been launched to remove errors from care processes. The emergence of
consumerism in health care is another factor. Health care leaders are responding to the
shift to more consumer-driven decision-making models, and to the oncoming
transparency of cost and quality measures. Lastly, in this new market, insurers and other
third parties are publishing information on the cost of hospitalizations, surgical
procedures and measures of quality for both, such as infection rates. Web sites
providing comparisons between hospitals and doctors are becoming widespread. There
is recognition that fundamental change is needed in lieu of applying the next Band-Aid.
Leaders have also recognized that the emerging application of the electronic and
integrated medical record provides new tools to reengineer processes. These electronic
tools immediately and simultaneously strip away the delays of waiting for results, images
or consultations. No longer should the patient hear, “we are waiting for [fill in the blank]
to take the next step in your care.” The movement of paper becomes obsolete.
Moreover, as conventions for presenting the information in a standardized way are
normalized, the time to decision and service will be reduced.
To be sure, there is curiosity about lean techniques among health care leaders. Many
are waiting and watching to see if this is a fad. On the other hand, a growing number of
organizations have launched lean programs or experimented with rapid improvement
“Kaizen” events. They are learning new principles, a new language of improvement and
how to apply them to flawed health care delivery models. The language includes terms
like value streams, Takt time, one-piece flow, just-in-time (JIT) materials, process pull,
the flow of health care, level loading work and andons to “stop the line” when there is a
defect.
Applications in design
Lean practitioners would point to the method used by manufacturing referred to as
“3P”—for production, preparation and process—as the “gold standard” approach. This
3P method seeks to design the quality of the product to be delivered at the required
demand and the correct time, and designed to meet customer requirements with simple
low-cost processes. Inherent is the need for deep process knowledge that is much
deeper than what is typical within health care organizations.
Few health care organizations have the background, resources or commitment to a
series of structured workshops that integrate workflow design with facility design. Since
few organizations are ready for 3P, other less rigorous yet effective approaches are
emerging in response to the burgeoning interest in rehabilitating workflows and facility
design.
Matching the methods
In any design effort, the design team matches its methods to the health care client’s
objectives for the project. Adding a lean consultative service to the design team must be
contoured to the organization’s readiness. The design team should assess factors,
including client leadership beliefs and approach to workflow improvement, the existence
of infrastructure to support process improvement and the ability of the design team to
collaborate and integrate lean concepts. The assessment should drive the scope of the
work and opportunity for breakthrough results.
Recognizing the value of lean techniques, some architectural firms have employed
workflow or lean specialists. Similarly, consulting practices are tooling up to offer
comparable services. Trained either in manufacturing or by university-based courses,
lean consultants use tools to expose flawed processes, help users see through a new
set of lenses and redesign processes for reliable performance. Improved processes
drive improved design and improved efficiency. In essence, the work is addressing the
fundamentals of what happens in the workplace to ensure all the resources or “flows”
come together in the right place, in the right quantity and at the right time to support the
care provided without error. The flows of health care include patients, equipment,
supplies, care providers, information, medications and process design.
Basic lean principles
While the scope of the lean consultation can be scaled to the client’s readiness, little
value can be achieved without a basic understanding of key lean principles. A
description of these principles and the implications to facility design work follows. Use of
these fundamentals introduces the application of lean to design, prompts breakthroughs
in design, yet is much less intense or comprehensive than 3P.
Seeing the waste: Value-added versus non-value-added work. The most basic of the
lean principles is the understanding of waste in work processes, so that everything done
adds value to the customer. All users acknowledge that waste exists, but few can
quantify it. The definitions in the sidebar at left provide a common language that helps
users see the waste and separate value-added and non-value-added tasks.
Tools like spaghetti charts (essentially a road map of the flows on an architectural
drawing) demonstrate redundancy, how tasks are reworked, highlight unneeded
movement and further help qualify the opportunity for improved design-work process
and space. Another tool, process cycle time, reveals variation and delays to care
previously not apparent to the user. Using these and observing how the work is done “on
the floor” and not in a conference room yields a deeper understanding that converts to
better design.
JIT and 5S. JIT and 5S (sorting, simplifying, sweeping, standardizing and self-discipline)
are two other practical tools for space planning. Essentially, JIT is the principle of
bringing all the resources needed to the point of use, at the right time and in the right
amounts. This includes clinical knowledge, skilled hands, products and technology. Too
often, because there is distrust in the supply chain or in the reliability of the electronic
information system, there is waste in overstocked supply cabinets or unreliable updating
of information.
Drawing from the technique known as 5S, design teams and users first understand the
flows and the quantity of products needed and design the supply chain to deliver
resources to the point of service. 5S also emphasizes making resources visible at a
glance and more accessible. Searching is eliminated. Common tools are shadow
boards, kanban, floors taped to demarcate where equipment is parked, reducing the use
of unnecessary doors and arranging resources in the work space to support an orderly
and sequential workflow to minimize effort.
Applications of these techniques reduce the number and length of design sessions,
reduce excess storage space and prompt uniform design standards for all spaces.
Standard work. Variation is the enemy of reliable performance. As technique and health
care practice has evolved, variation has grown commensurately. To achieve
breakthrough efficiency, the most challenging task is achieving with the user high levels
of compliance to standard work. Here is a working definition: Standard work is the bestknown way that is agreed upon and practiced by all. So, process variation is reduced or
eliminated, outputs are reliable and repeatable, clinical judgment is preserved, the
handoff of work to the next caregiver user is clear, accurate and supported by visual
management tools.
Often clinicians, in particular, resist the principle of standard work, equating it to
cookbook medicine. Once understood and applied in practical settings, resistance
dissolves, particularly when it is understood that clinical judgment is rarely impacted.
Making the process visible. Visual management, or the use of displays to demonstrate
if the “assembly line” is running on plan, is a common tool in manufacturing. Different
from manufacturing, the processes of health care are rarely visible. Hence, delays occur
because the patient’s progress is not apparent and intervention is not timely. Few
effective visual management tools exist in health care. There are crude tools, like the
whiteboard in OR or computerized signals in the laboratory, but they rarely satisfy the
need to make the process visible. Hence, the awareness by caregivers of delays or
errors in the workflow is coincidental. Gaps in service are not anticipated or resolved.
That is the essence of visual management.
Traditionally, the paper medical record has been the primary tool to monitor care. Visible
to only one caregiver at a time and chronically incomplete, it has been an inadequate
tool.
Only recently has the electronic record migrated to a real-time tool, available to many
simultaneously. Still, it is rarely formatted and used as a visual management tool.
Designers have the responsibility to ensure that there are sufficient displays (monitors)
indicating a patient’s progress from the plan of care (standard workflow). They must also
ensure that the software signals variation in process performance.
Short of this more elegant solution, there are other simple tools to make processes
visible. Consultants can facilitate development of tools once the users understand lean
principles. Like manufacturing, the user should signal a “line stop” and usher more
resources to reduce delays, defects and other wastes.
Bringing it together
Architects often use room mock-ups during the design process. Typically, the goal is to
help hospital staff visualize the space and verify room orientation. Mock-ups help the
design team locate equipment, outlets, medical gases and other devices. Sometimes the
mock-up is also used to confirm finish, material selections and room lighting. However,
mock-ups are rarely used to their full potential.
Coupled with lean principles, design is raised to a higher level of effectiveness to ensure
mock-ups model the best-known processes, standard work and to ensure safe, defectfree and efficient delivery of patient care. Simulation of high-value workflows (those that
are frequently run, prone to be highly variable or with defects) verifies how well these
spaces support patient care. With equipment and products in the mock-up spaces,
caregivers demonstrate processes and reveal potential design flaws.
This approach was used on the recently designed Maple Grove (Minn.) Hospital. The
mock-up area, dubbed “The Mock-Up Village” by the design team, included mock-ups of
a med-surg room, labor-delivery-recovery room, critical care room, ED treatment room,
prep/recovery area, OR, loading dock and materials management area. Inexpensive and
easily modified materials were used to construct the mock-ups.
Once oriented to the lean principles and the proposed design and objectives of
simulation, users were guided by designers and the lean consultant demonstrated highvalue processes. Simulations were conducted over several sessions; changes were
made and retested. Design elements were verified or changed and all resources were
positioned to support standard work as well as being ergonomically correct.
High yield, low investment
A relatively low investment in the application of lean principles should yield right-sized,
flowing processes with the lowest practical levels of waste; less total time devoted to the
design process; less rework in design; and fewer construction change orders.
The principles outlined here should give health facility designers a good start toward
achieving those ends. n
Scott Holmes, AIA, ACHA, LEED AP, is an architect and medical planner at BWBR
Architects in St. Paul, Minn. He can be contacted via his e-mail address at
[email protected]. Dan Schowengerdt is an independent consultant and a former
health care senior executive. He can be reached at [email protected].
About this series …
“Architecture+Design” is a tutorial published quarterly by Health Facilities Management
magazine (www.hfmmagazine.com) in partnership with the American College of
Healthcare Architects (www.healtharchitects.org).
This article first appeared in the March 2008 issue of HFM magazine.
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