Mark's note: Here is a guest post by my good friend Naida Grunden, author of two great books on Lean Healthcare.
America's 5000 hospitals face a perfect storm: aging facilities that need renovation, replacement, or seismic retrofit versus a vastly shrinking healthcare dollar. The 1946 Hill-Burton Act, which extended federal funding to build hospitals and improve healthcare access in rural and poor areas, set off a hospital building boom that lasted 40 years. The boom is over. Change is in the air.
The Patient Protection and Affordable Care Act asks us to look differently at the way care is delivered—no longer as a disconnected batch of cottage-industry services, but as a continuum of care. To compete on quality and safety in this new era, hospitals will have to provide consistently efficient and excellent care to every patient.
Now factor in some other changes. The practice of medicine is morphing, with lines blurring between inpatient and outpatient care; between the services of physicians and other clinicians; between acute and chronic conditions. New technology can extend services of the major urban center to rural areas.
If change is the new normal, how can the hospital building be designed to serve efficiently today and into the future? Here are the certainties: hospitals can neither afford to build one extra square foot, nor build something today only to remodel it in a couple of years, nor take on massive new debt.
Where will the money come from? Here's an important place to look: the extraction of waste from the current systems of care.
Good Time for Lean Thinking
Fortunately, Toyota-based Lean philosophy has begun to permeate hospitals and health care, and the result has been an impressive number of examples of improved quality and reduced cost in the systems of care—from supply chain to infection control to clinical processes themselves. Now, a new and intriguing area of Lean inquiry is emerging: Lean facility design.
Any hospital leader, employee or trustee serving during a hospital remodel or rebuilding program knows that the process can be daunting. But leading with Lean thinking, starting from Day One, can offer a fresh perspective, and a way to remove massive amounts of waste. Lean-led design can help make the new facility congruent with the processes it houses, and flexible for use now and into the future.
Leaders at one Kentucky hospital felt certain that the new facility it was designing would need space and equipment for two new CT scanners. They based this notion on the fact that, with two existing CT scanners, they were unable to complete all inpatient requests on time, and were turning away outpatients. The “obvious” answer was to build more, build bigger, and add staff.
But when a team of observers used Lean methodology to see how work was currently done, a deeper truth surfaced: the existing CT scanners were often idle because broken processes upstream prevented the smooth flow of patients. Once the hospital addressed the problems of communication and transportation among various departments, patient flow became predictable and smooth, and the hospital discovered they had plenty of capacity.
Radiology staffers discovered that doing steady work in a reliable system was far less stressful; so although 120 more patients came through each month, the staff's stress level was, in the words of a frontline worker, “absolutely, perceptibly lower.” (In another happy side effect, revenue skyrocketed by $100,000 per month.)
The case demonstrates some key points to consider going into a big design project: 1) more often than not, the cry for “more” is really a cry for help to fix a broken process; 2) waste increases frustration, expense and error; and 3) more and bigger space is not usually the answer.
Traditional vs. Lean-led Design
For too long, hospital architects have been asked to proceed without crucial prerequisites—stable healthcare processes and the workflow that supports them. Traditional design puts design first; Lean-led design puts process first.
The usual sequence has been for the hospital leadership to ask for a hospital, and the architecture firm to take the lead immediately. The architecture firm usually conducts a series of department-level User Group meetings, then start designing and drawing right away. Architects may jump right in with functional and space programs, using square footage “formulas” and adjacencies from their other, most recent projects.
The floor plan that arises from this traditional approach usually reflects the way work is currently done in the hospital. Because the wishes of each department have been addressed separately, functional “silos,” hierarchies, and non-standard processes remain. Because the department leaders have had overwhelming influence, the voice of the caregiver may have been overlooked. Process improvements may have not been identified, so spaces may not be as useful and flexible as they might have been. Opportunities to design space that favors collaboration, standardization and efficiency have been lost.
In other words, the shiny new hospital has the same old functional problems.
Lean-led hospital design differs in several key ways. Initially, hospital personnel retain the lead in the project, with the architect as a valued team member. At all times, the focus is on the patient's journey, and pulling value to each patient. As with the CT scan team, Lean-led design begins with observation at the points of care. Multidisciplinary teams, drawn from all levels of the hierarchy, map each value stream, analyze processes, and arrive at consensus about how work might be done better in the new facility.
A team in one Wisconsin hospital followed a patient's journey for an outpatient cardiac procedure. When they discovered that the patient had to go to 13 different locations on four floors during their journey, they completely re-thought the space they were designing in their new facility. (In fact, they were so upset by the current state that they redesigned the whole process in the old building as well, making it faster and better for patients.)
Observing and mapping the patient journey encourages collaboration during design. That collaboration lays the groundwork for better communication in the new building, and other benefits like standardization, less square footage, less equipment, less storage space, and fewer and better patient handoffs.
The consensus-based future processes now drive the development of the floor plan. Architects now start drawing, and the resulting floor plan diagrams are used to validate the value stream and future state. At each step, the whole team has the opportunity to measure whether the resulting design will improve the patient's journey.
Results
Collaboration saves money and results in a better building. Lean-designed hospitals across the country are discovering the benefits of:
- Investing hospital resources (people and time) up front in the design process.
- Observing and mapping the patient journey before asking the architect to draw a floor plan.
- Encouraging design input from all disciplines and all levels of the hospital hierarchy; as well as from the architects, engineers, construction managers and trades people.
Two nationally honored examples include the Bellevue campus of Seattle Children's Hospital. Through Lean-led design and a unified building contract[i], the facility came in 25,000 square feet smaller than its original estimate of 110,000 square feet—and $40 million below its original $100 million budget.
ThedaCare in Wisconsin test-drove their new process model, the Collaborative Care Model, in a pilot unit that they and their architects designed and perfected for two years. Once they achieved zero medication errors for 18 months, reduced costs by 25%, reduced length of stay and readmissions, improved staff satisfaction, and increased patient satisfaction to 100%—only then did they consider “cloning” the model.
Architects cannot create lean hospitals by themselves. The lean hospital is not so much a building, but a state of mind that constantly looks for ways to reduce waste and increase value.
The Future of the American Hospital
How can the hospital of the future thrive? Patient experience will rule: any effort that does not speed the patient back to health will be recognized as waste. The hospital will use 100% of its space, 24 hours a day. It will be smaller. Spaces will flex among services. Processes will remain nimble and continuously improve. Costs and timelines for design, construction, and operation will decline. Collaboration between healthcare workers, hospital executives, architects, and construction experts will be established from Day One of any construction project.
Most important, Lean will no longer be a “fashion statement,” but will be interwoven into every aspect of work, a prerequisite to excellence.
Naida Grunden is the author of The Pittsburgh Way to Efficient Healthcare, and is the co-author, with Charles Hagood, of Lean-Led Hospital Design. Both books are recipients of the 2013 Shingo Research and Professional Publication Award. For more information, go to www.naidagrunden.com or www.hpp.bz.
[i] In construction, architects, engineers, construction managers and trades persons have begun to innovate with Lean through Integrated Project Delivery (IPD), in which one contract covers all services. Collaboration and interdisciplinary communication are mandatory, as construction targets and financial incentives align to encourage it. Design-bid-build, rather than discrete and sometimes competing endeavors, becomes a single continuum of service. Seattle Children's used a type of IPD for their project.
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Bravo Naida
Whether a hosiptal or any other business before letting the architect design the building or thr remodeling plan, we should all stop and consider how it will really be used. We should first make sure that we know how the process will flow so that we put all the parts in the right place. But in the end we have to stop departmental thinking and start with process understanding.
I have a friend that has been involved in their firms redesign, at one time their testing facility had one lab located near the main offices. When they looked at all the equipment they realized they in fact had at least five fully equiped labs, once they looked at what each process they ran actually needed they found their lab could equip seven dedicated testing labs (one attached to each of their seven process lines). After shifting them so each process line had its own lab they found that obtaining test results speed up dramatically, they required 10% fewer staff for testing (they spent less time walking), and their output increased by 20%.
I have seen the exact same thing in hospitals were departmental structure actually gets in the way of using the equipment that is already there to its true capability, simply because they spend time waiting for patients to get transported to them or waiting for staff to bring samples back. The only drawback to better design will be that some hospital staff will find they get less exercise.
Before reading this I’d never considered how imperative it is for healthcare centers to implement Lean philosophies and practices. I’m very familiar with and supportive of Lean principles as my business uses them, and as someone who needs the healthcare system in her life, I fully support your cause. Of course I want hospitals to run as efficiently as possible – regardless of whether they are inpatient or outpatient hospitals, and regardless of why I’m in that specific hospital and how long my stay is! I will definitely look into your books, Naida. Thank you for sharing this issue with us all!
Thanks – and it’s not just “as efficiently as possible” but also the goal to work “safely as possible” for everybody involved.