Lean design can minimize waste and maximize patient value in healthcare facilities

December 17, 2019 Teresa Endres

From visioning through design and into operations, Lean principles can eliminate challenges like supply hoarding and unnecessary waiting

 

I recently spoke alongside Dave Ring, California Office of Statewide Health Planning and Development’s North Region supervisor, at a Lean Construction Institute event. Our panel focused on leveraging Lean and integrated practices and tools from early in planning through design and even through the permitting process. 

It’s important to understand the value of Lean, where we can find waste in the healthcare field, and how Lean practices can truly minimize that waste and maximize patient value. Planning, designing, and operating with a Lean approach is the most effective way for healthcare organizations to function.

 

Open infusion bays provide flexibility and access to daylight and a view outdoors for patients, families, and staff at the UCSF Precision Cancer Medicine Building (PCMB) at Mission Bay in San Francisco, California. Using Lean design principles helped optimize floor space.

 

What is Lean? 

Lean originated in manufacturing, but the principles can be applied to facility operations, the design and construction process, as well as management. The principle is to minimize waste while increasing value and quality, mainly through improved processes, communication, and collaboration.

But Lean isn’t just a tactic or a cost-reduction program. It’s a way of thinking and acting for an entire organization. The concept of transformation or Lean transformation is often used to characterize a company moving away from an old way of thinking. It requires a complete adjustment on how it conducts business, which takes perseverance and a long-term perspective.

The applications of Lean in healthcare are vast, and the potential savings can be significant. The savings are not just in the design and construction of healthcare facilities but in the daily operations and the delivery of care. For healthcare facilities, the benefits include improved patient satisfaction scores and a reduction in operational costs.

 

The TUGS robotic system provides UCSF PCMB with efficient, accurate, just-in-time delivery of materials, an important part of Lean design and operations.

 

“Hoarding” in healthcare

The audience laughed knowingly when I told an anecdote from when I was on a planning team for the design of a replacement hospital. As we walked through the 1950s-era facility being replaced, I opened the door to what I thought was an IT closet to find it filled with medical supplies that should have been in the clean supply room.

And why does this happen? Not because facility staff are hoarders in the traditional sense. It happens because healthcare staff are often dealing with life and death situations—they can’t afford not to have critical supplies within arms’ reach, leading them to stash supplies in convenient locations as a workaround for the inefficient and inaccurate management of materials.

By incorporating Lean into the planning of a facility and tying the planning to the facility’s Lean operational model, a facility’s inventory of clinical supplies, medications, and mobile medical equipment can be tracked, reordered, and delivered in an efficient and precise manner. 

Here’s a tangible example of the impact of Lean as it relates to the issue of “hoarding” in healthcare: the implementation of a just-in-time (JIT) delivery system for the distribution of clinical supplies. A JIT delivery system incorporates technologies—including asset management—where all clinical supplies are inventoried into a tracking system, and when the item is used/checked out it is automatically reordered and delivered to maintain a consistent inventory. There are many systems for managing inventory, such as barcode systems, radio-frequency identification, and real-time locating systems (RTLS). Each system has advantages and disadvantages, so research is important.

 

Where’s the waste in healthcare?

Taiichi Ohno of Toyota, the originator of Lean principles, described seven areas of waste that occur in every industry (Toyota has since identified an eighth waste). It may seem counter-intuitive to apply what has worked in manufacturing to a hospital or clinic setting. However, implementing Lean in healthcare and reviewing processes and systems through the lens of the eight wastes, organizations can potentially reduce that waste, increase efficiency, and save on operational costs all while improving the quality of patient care.

Here are the eight wastes and their impacts in healthcare:

  • Defects: variation in outcomes, medical errors
  • Overproduction: redundant work, chart duplication
  • Unnecessary waiting: patient queues, staff idle time
  • Confusion/Skills: best practices are unclear, underutilizing capabilities
  • Transport: delayed delivery of supplies and materials
  • Inventory: excessive supplies (hoarding), unused medications
  • Wasted motion: unnecessary movement by staff, patients
  • Excess processing: more work or complexity than is required

It isn’t until after we’ve identified the types of waste that we can overlay this information in the planning and the facility can create a process to eliminate or reduce that waste.    

 

A flexible variety of team working spaces enhance care-team communication and collaboration in providing patient care and meeting the PCMB guiding principle of patients first.

 

How does a Lean operational model correlate to Lean programming and planning?

One of the main principles in Lean is the team. Trust, collaboration, and communication are the foundation of a Lean team, and various tools are used to enable the team to make consensus-driven decisions.

When we design a new/remodeled department or new/remodeled healthcare facility using Lean principles, it’s imperative that we incorporate Lean practices throughout the life of the project. Our goal as designers is to engage project stakeholders throughout the project lifecycle and into the operations of the new department or facility to ensure success far beyond just the design and construction of the building.

_q_tweetable:Lean isn’t just a tactic or a cost-reduction program. It’s a way of thinking and acting for an entire organization._q_

Due to the complexity of healthcare projects, there are many project stakeholders beyond facility executives and the end users. Typically, there is a core team—the project manager, selected end users, the architect, healthcare planner, and, on integrated projects, the contractor—that lead the project (in collaboration with strategic internal and external stakeholders) throughout design and construction. Collaborating with the contractor and other team partners early in design increases the project’s effectiveness and success.

Seeking input from a wide variety of project stakeholders to create the Lean operational model allows a facility to ensure all aspects of operations are considered and every detail of operations and flow of patients, staff, materials, medication and equipment are incorporated into the Lean operational model. This information is used during programming and planning to adequately size the facility and create an efficient layout.

In non-Lean projects, savings and efficiency in the layout of the facility are limited because the programming and planning are not tied to an efficient operational model.  For example, if supply rooms are reduced in size and/or quantity without a JIT delivery system, the new facility will encourage supply hoarding like we discussed earlier. And this could compound over the entire facility if spaces are reduced or removed to save on first cost (construction) without addressing the operational systems required to support the reduced support spaces.

Establishing the project vision and scope, as well as determining critical success targets, involves one or more group-visioning sessions, data collection, and benchmark research. Then, you can synthesize the results to create a unique project vision.

Since one hallmark of Lean process improvement is that you cannot change what you cannot measure, this process must be data driven. We work with our clients and project partners to obtain and review data about current market share and demographic change. We collect existing parameters surrounding patient care. In a clinic setting it would likely include wait times—before first appointment, to get into a specific treatment queue, etc. In an acute-care setting, we might collect data on nursing unit challenges that impact the delivery of care, including nursing staff travel distances to support spaces, charting, errors in medication, and more.

When Lean principles are not leveraged throughout the life of a project, reduction of waste may not be identified or measured, potential efficiencies may not be realized, and patient care may suffer. For example, using autonomous robots to deliver clinical supplies, medications, meals, and lab specimens allows for fewer holding rooms—reducing the overall footprint of a new facility. A reduced footprint and JIT delivery can also reduce the volume of supplies. Autonomous robots can improve clinical efficiency in multiple ways, allowing nursing staff to spend their time on patient care and not logistics of meals, medications, medical supplies, or lab specimens.

 

The new UCSF PCMB offers a variety of waiting spaces and amenities, giving patients and their families flexibility. The seating options include booths for groups or more private discussions, swivel chairs for varying conversational groups, sofas, recliners and table/chair sets.

 

Why should you care, and how do we know Lean is effective?

So, why should you as a hospital administrator, physician, or fellow designer care about Lean and its implementation throughout the lifecycle of a project? Honestly, effective design can’t resolve every issue. The key is finding the sweet spot between architectural design and operational adjustments.

In Stantec’s recently completed UCSF Precision Cancer Medicine Building (PCMB) at Mission Bay, UCSF is utilizing the TUGS autonomous robot system for the delivery and pick up of materials. Not only has this resulted in reduced footsteps and increased efficiency for the clinical staff, it also allows UCSF to store minimal supplies in the supply rooms and exam rooms because clinical supplies are delivered just-in-time with a combination of the TUGS and an inventory-management system.

For the PCMB project, UCSF fully embraced Lean in every aspect of the project: Lean operations, Lean programming and planning, and the project was built using an integrated (Lean) delivery model. By embracing Lean in planning and operations, our team was able to create an efficient flow in the planning, resulting in efficient square footage.

In addition to using Lean to improve process flow, we also optimized floor space and inventory. This allowed UCSF to realize one of their guiding principles of patient first care, as illustrated by the open infusion bays which allow daylight to bathe the infusion bays with natural light and provide patients and their family a positive distraction (the view), all while delivering superior care in a highly efficient building.   

 

A hand-in-hand Lean approach

Partnering with a Lean planning and design team to help implement a Lean operational model will help improve healthcare outcomes and patient satisfaction, reduce costs, increase value and staff retention, and improve efficiency.

To ensure success when employing a Lean approach, it is crucial to keep in mind that Lean programming and planning go together with a facility’s Lean operational model. It is essential to recognize that without a healthcare facility fully embracing a Lean operation model, the success of Lean programming and planning will be limited. And then you end up with supplies in the IT closet, and nobody wants that.

About the Author

Teresa Endres

Teresa Endres, AIA, is a senior associate in our Buildings group in Sacramento, California. Focusing on ultra-specialized facilities, she uses her expertise in Lean hospital transformation to bring visionary projects to life.

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