Lean in Hospital Design; Improving Quality, Patient Safety, and Employee Engagement

Posted on 21-May-2020 at 05:21 AM

Healthcare organisations are currently facing major challenges, including declining reimbursements, competing on patient wait times and satisfaction, and complying with time-sensitive care standards for high quality care. When designing healthcare facilities, it is important to consider more than architecture and construction. Taking a comprehensive view of operations includes considering the impact of four components on the overall system: people, processes, technology, and place. Taking these into consideration, healthcare organisations can achieve results in the three key aspects of their business: quality, efficiency, and experience. One way to achieve these results is through the use of Lean.


When architects use Lean methodologies to tackle questions of growth or change, the people who do the work in the space participate in the design process and are challenged to examine wastes in their current work flows from a new perspective. The objectives shift so that the building (whether renovated or new) is looked at as a tool for better patient outcomes and experience, staff satisfaction, safety and flow.


Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer’s needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited.Based on the Toyota model, it focuses on how efficiently resources are being used and ask, 'what value is being added for the customer’ in every process. Recently, the health care industry has demonstrated success in applying these principles in the United States, United Kingdom, Australia and now Canada. The application of lean management in health care can also be holistic such as the transformation of an overall business strategy.


In Lean design, both client and architect engage in a different mindset. The architect no longer rushes to show the client several layout options before understanding the process flows. Clients commit staff and time up front to observe and map the patient journey. Multidisciplinary teams (which also including patients and families) then work together to develop and test the best work flows that encompass the entire spectrum of care: patient, family, providers, staff, equipment, information, supplies, medication, and instruments. Multiple solutions are tested until the team creates improvements to the patient’s journey and new process flows that remove waste. In this process the architect acts as a facilitator for improvement opportunities. As architects translate the team’s new work process and patient experience improvements into physical space, there are clear performance goals in sight. 

 

Organisation commitment to lean


The first step in Lean design is to identify the organisation's commitment to Lean methodologies. Organisations often look to leverage the opportunity of a new facility to rethink how business is done. There is no one-size-fits-all approach to improving efficiency or achieving better operational results. The organisation's culture and goals are key variables. Determining where the organisation falls on the scale below will help to define a process and design solution that matches the organisation's needs.


Organisation's interest in lean design


The next step is to identify the nature of the organisation's interest in Lean design. Lean can have many connotations in healthcare design. Most often, the healthcare organisation's interest lies within these categories:

  • Lean facility - Design a facility that is smaller, costs less to construct, or is more energy efficient
  • Lean design processes - Reduce the time required to design a facility
  • Lean operating processes - Improve the efficiency in operating a facility through reduction in the time it takes to do work, improving the quality of the work, and lowering operational costs.


When an organisation's interest is in the design of a Lean facility, it is prudent to perform a current state assessment. The purpose of the assessment is to understand the project goals and justification before beginning design.Instead of asking what the organisation wants, seek to understand what the organisation is trying to accomplish, in terms of results.Instead of asking what the organisation wants, seek to understand what the organisation is trying to accomplish, in terms of results.


In the case of an organisation interested in Lean design processes, the designer's organisation must apply Lean to the architectural process. The architectural process is generally linear, with each phase unable to start before the previous phase is completed. Exacerbating the linear structure of the architectural process is the invalidation of the previous phase of a project during subsequent phases. A lean design process incorporates overlapping phases of the architectural process, resulting in a speedy design process, as well as better utilisation of the organisation's staff time.


Lean operating processes is the third category of a Lean design request. Lean operating processes can be achieved through incorporating key Lean principles into design, such as flexibility. Another way to assist a healthcare organisation with achieving lean operating processes is by spanning the operational planning phase throughout the entire architectural process. Instead of having operational planning as one component in a linear architectural process, use operational planning as the 'glue' to provide continuity from phase to phase. This ensures that designs are driven by operations and the facility supports the functions that must take place within the facility.


Value stream mapping


Lean focuses on increasing the value delivered to the customer. The first step is to define the customer. In healthcare, the customer is often the patient, but may also be the physician, patient's family, or another healthcare organisation. After identifying the customer for a specific process, the value delivered to that customer is measured. Value stream maps analyse a process from the customer's perspective and demonstrate the value delivered at each step of the process. Key components of a value stream map include:


  • Steps of the process
  • Categorisation of each step as value-added (something the customer would be willing to pay for), non-value added (waste or something the customer would not be willing to pay for), and non-value added but necessary (something the customer would not be willing to pay for, but is necessary to the process, such as regulatory requirements)
  • Quantification of the amount of time required for each step.

Lean process mapping

Process mapping is another visual way to understand a process. A process map is similar to a value stream map in that it conveys the steps of a process. However, a process map does not necessarily convey value nor does it view steps from customer's perspective. A process map can convey processes as simple as making a sandwich or as complex as patient flow through an entire facility. There is one main component of a process map: the steps of the process.


Lean waste elimination


Another key concept in Lean is the elimination of waste. Waste is any action that the customer would not be willing to pay for. There are eight types of waste in processes:


Waste

Description

Examples in Healthcare Organisations

Overproduction

Processing too soon or too much

Reception staff preparing multiple clipboards with forms in advance of patient’s arrival

Defects

Errors, mistakes, rework

Mis keyed information in the registration system, medication errors

Inventory

Holding more inventory than required

Stock-piles of supplies and equipment in some areas while others were short of the same supplies and equipment

Over-Processing

Processing more than necessary

Patients repeat the same information multiple times to various workers

Transporting

Moving items unnecessarily

Many hands-offs of the patient and his/her information amongst various workers

Waiting

Employees or customers waiting

Employees at the triage area waiting to see the patient while the patient is being registered at the registration desk; patients waiting in waiting areas or the exam rooms

Motion

Moving people more than required

Workers moving from exam rooms and back, workers hunting for supplies and equipment

Unutilised people

Not leveraging workers to their fullest potential

Staff overworked in certain areas and sitting idle in other, making them do tasks they are not hired for

 


By identifying these wastes in processes, the processes can be modified to eliminate waste. Through this exercise, costs are reduced, quality is improved, and worker engagement is encouraged. This can be applied to both the healthcare organisation as well as the designer's work.



References:


1.       Using Lean in Healthcare Facility Planning and Design; Amanda Mewborn, Senior Healthcare, Operations Planner, Perkins+Will, US.MarvinaWilliams,  Senior Associate, Senior Medical Planner, Perkins+Will, US.

2.       Lean Hospitals, Mark Graban MD, second edition, CRC Press.

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