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Healthcare reform has driven and intensified the challenge of transforming our healthcare delivery system to reduce costs and improve patient care, as mandated by legislation such as the Affordable Care Act and the 2010 Patient Protection Act. These transformations place new demands on hospitals to improve the quality and safety of patient care delivery while containing costs, requiring hospitals to provide more efficient care. In addition to changing how hospitals operate, these demands will change how healthcare facilities are designed and built.
Lean principles, originally developed for manufacturing, are being applied to the operation and design of healthcare facilities with the goals of eliminating waste, reducing patient wait time, improving patient safety, and lowering healthcare costs. There are many differences between the traditional design process and one that incorporates Lean operations improvement activities in the design process, including philosophy, perspective, design milestones, amount of time spent in each phase and the people involved in the design.
|Traditional Design Process||Lean Driven Design Process|
|Design Focus||Focus on processes that add value for the patient, staff and family members|
|Starts with programming||Starts with observation of operational processes|
|User groups are made up of staff leaders within a department or service||Value-stream focused teams include key stakeholders who are involved across the whole process of delivering the service to the patient are used to analyze the process|
|Each user group provides feedback to designers about their departments or services||Multidisciplinary consensus based, future-state processes drive the development of the floor plan|
|Floor plan diagrams are adjusted to accommodate existing operations and processes||Floor plan diagrams are used to validate the value stream, optimize future improvements|
The Traditional Design Process, led by an architecture team, typically follows these phases:
Master Planning: This phase typically begins with a strategic plan analyzing how the facility will renew itself over time. Master plans often focus on architecture rather than operations, creating diagrams, plans and renderings of what the building(s) could look like in the future.
Predesign: The architectural team explores concepts for site, functional program block diagrams and adjacencies along with budget and time frame with the hospital leadership. As predesign progresses, the program begins to take shape, describing the number and size of rooms and departments based on historical data, formulas and projected volumes. If operational processes have not been reviewed prior to programming, unnecessary spaces may be added to the program. The team develops a few options for the design and form of the facility based on the programmatically informed block diagrams. Predesign ends with the leadership selecting a scheme to be further developed in next phases.
Schematic Design: During schematic design, the initial block diagrams begin to evolve into departments with rooms. Adjacencies and circulation patterns are established and building support spaces including elevators, stairs and columns are located. The architectural team meets with user groups that typically include department managers and select staff members to review and refine the plans. Other disciplines are added into the team, such as engineers and landscape designers to further refine various aspects of design. Schematic design ends with sign off on locations of departments, adjacencies and key rooms. The general contractor may be involved in this phase or in design development to study the work for feasibility and cost.
Design Development: This phase focuses on refining each room, exploring placement of equipment, casework, electrical, telecommunications and IT systems. Meetings with user groups occur to discuss the operational flow of individual rooms. At this phase, it can be difficult to change departmental circulation and major component placement.
Bidding/ Documents/ Construction: After design development, meetings with the user groups end and the team prepares construction documents, finalizing the decisions made in design development. Traditionally, each discipline has an individual contract and coordination has to be managed while maintaining the schedule, which can be difficult.
Move-in/ Post occupancy: Upon completion of the hospital, architects and engineers review operating procedures of specific areas, including the physical plant and HVAC systems, with key hospital staff. In some instances, a cohesive plan for move-in is created and followed to better locate supplies and equipment.
Traditional design is, more often than not, begun without an extensive review of the existing operations and processes in the current facility to determine what may be needed to evolve the quality and efficiency of care to meet the demands of an ever changing healthcare market.
Another approach to healthcare facility design, the Lean-Driven Design Process deliberately engages the facility stakeholders in the initial design process, with a focus on reviewing operational processes to eliminate waste and improve efficiency. This review yields a plan for how the hospital would like to operate that forms the basis for the architectural design.
Master Planning: As in traditional design,master planning begins with the development of a strategic plan that analyzes how the facility will renew itself over time. However, in Lean-Driven Design, the focus is on how the provision of healthcare could be improved in the future. Data is collected for service areas and ideas for how these areas might work together in the future are developed. If the project is located on a green field site, the team can utilize a tool developed by Toyota, 3P, which stands for product (patient care), process and preparation, to evaluate the optimal services and operations for the project. This tool offers the team a way to think about new and improved methods for eliminating waste through product and process design.
Predesign: In predesign, hospital leaders continue to develop the 3P. Teams, consisting of the architecture team, operations consultants, staff and hospital leaders, are formed to explore day-to-day operations and determine which service areas will be impacted by the project and to plan, at a high level, how these services could be carried out more efficiently in the future.
Process Mapping: A clear departure from the traditional design approach, Process Mapping takes an in-depth look at existing and future hospital processes. The teams examine each operational process from the point of view of the patient, staff and family members, highlighting value-added activities and non-value-added activities through observation and process mapping of the current state of operations. Each step in a process is mapped diagrammatically with additional layers of analysis, such as the time it takes to complete the task and the value of that task, and then added to the diagram. Once the current state maps for each area are completed, unnecessary steps and problems are discovered and solutions are brainstormed to create future state maps showing how processes will be done more efficiently at the new facility. This phase differs from the traditional design approach in that there is considerable effort in the early phases gathering information, defining value and reviewing processes to inform the program and design effort.
Design: The traditional design process phases, schematic design and design development, are focused on achieving the level of detail and documentation required for design approval and cost estimation of a facility’s design. The Lean-driven design process combines these phases to create an integrated approach that relies on the information gathered about intended operations of the service lines discovered in the early phases of the project to support the design effort. The design is focused on efficiency and standardization to limit process variation, increase flexibility and improve the quality of care. This focus strengthens the future operational processes, encourages smaller design iterations, and results in less design rework. Small, simple mock-ups are created to allow teams to run quick process simulations and test design ideas. Detail is added as a response to the simulations, after a mock up room is correctly sized and operations are tested. Other disciplines such as engineers, equipment planners, and interior designers participate at key points to offer solutions and to understand the impact of the future state on their contributions to the design. Decisions are structured to be made just in time instead of being based on traditional deliverables. Once these decisions are made about the design, production begins.
Integrated Project Delivery (IPD): To facilitate comprehensive understanding of a project, enhance communication of all parties involved in creating and delivering a building, and to improve upon coordination challenges of traditional design, Lean-Led design often includes IPD. Integrated project delivery typically relies on some form of a single contract and close collaboration among all participants from concept through completion. These participants include the owner, architects, design disciplines, general contractor and often subcontractors at the outset. The bid and negotiation processes are interwoven with design, which eliminates the need to spend additional time on this step. IPD has been shown to increase efficiency, reducing the total time needed to complete the project. It also focuses the entire team on value to the end customer, which is not always the focus in traditional projects.
Move-in/ Post occupancy: Similar to traditional design, the operating procedures for key equipment are reviewed with the staff. Additionally, to increase standardization and efficiency, workplace organization is implemented, based on the Toyota 5S and visual workspace principles. The 5S acronym stands for Sort, Set in Order, Shine, Standardize and Sustain. In a healthcare facility, 5S can be applied to medication, supplies and equipment organization. Visual workspace organization creates well identified “homes” or locations for equipment, supplies and medications that are clear and consistent. Such careful pre-planning makes finding and replacing items simpler for staff. Workspace organization involves the staff in the placement of items, creating a smooth transition into the new space.
As healthcare looks to maximize every dollar with a focus on patient care, safety and works to eliminate waste, Lean-Driven Hospital design offers opportunities for healthcare facilities to understand and improve their work flow and processes to inform the design of their hospital. The result is a facility that is efficient, standardized and flexible. These features improve the ability of hospitals and staff to consistently provide excellent patient care, as well as continue to review and improve operations and processes in the future.
Lean-Led Hospital Design: Creating the Efficient Hospital of the Future, Naida Grunden and Charles Hagood
Bringing Lean Principles into Sustainable Design, Bernita Beikmann, AIA, DesignIntelligence
The Do’s and Don’ts of Lean Facility Planning, Bernita Beikmann, AIA, HealthcareDesign
The 3Ps of Lean Design, HKS
Lean-Led Hospital Design: Creating the Efficient Hospital of the Future, Reviewed by Ron Smith, AIA, ACHA, EDAC, HERD Vol. 6