As providers begin to understand the impact healthcare reform will have on their business, many hospitals and medical centers are looking to Lean process and design as a way to do more with less. Several elements of healthcare reform beg Lean solutions, such as the expected growth in outpatient care and more cost-efficient inpatient care, and, increasingly, designers are employing Lean strategies to create spaces that encourage Lean operations.

The changing healthcare delivery system

According to proponents, The Affordable Care Act is designed to contain soaring medical costs, cover more uninsured people, and increase quality of care. It is estimated that the act will provide insurance for 31 million Americans who are not currently covered. Important financial incentives will benefit providers that improve quality of care, driving a transformation from current practice to implement "integrated health systems." Healthcare organizations will be required to implement secure electronic medical records and establish standard billing methods, measures intended to reduce administrative costs and errors while also improving care quality.

The act’s provisions change the way providers do business, and how they will be compensated. Across-the-board reductions and productivity adjustments could result in $156 billion in cuts over the next 10 years. Physician ownership in hospitals will be more tightly regulated, requiring disclosure of physician self-referrals. Providers will not be able to shift their Medicare and Medicaid losses to other payers. Rate increases will no longer be tolerated. Competition-driven new building construction is expected to decrease, and already acquisition and merger markets are heating up as the industry comes to grips with the new rules. 

Impacting the built environment

The application of Lean principles can help some organizations streamline services enough to accommodate increased patient volumes in their existing facilities, while others may need to update spaces to maximize flow. Some regions will see an increase in family medicine clinics, which will act as "feeders" for hospital systems. It is expected that a decrease in physician-owned practices and the growth of provider/insurer models (such as Group Health or Kaiser Permanente) could spur increased medical office building development. An increase in urban neighborhood care centers, developed privately or by publicly owned providers, is forecasted to accommodate newly insured patients.

From reading numerous publications, we know that Lean is a way of thinking—a strategy for continuous improvement. The concept is straightforward: Lean is evaluating and improving healthcare—from the patient’s perspective. Removing waste from healthcare processes is the first step to improvement. Remember, waste is anything that does not add value for the patient. Improvements are measured by better outcomes, increased patient safety, and lower costs.

Improving healthcare design

While design alone can be shown to improve some processes, a truly Lean approach generates operational improvements first, then follows with improved design, thus creating an apt example of Sullivan’s "Form Follows Function" rule. Both time-tested and new design tools are being applied to Lean healthcare projects.

Reinvent the medical planning process

Lean experts implement a rational approach to operational decision-making: Launch the decision-making leadership team, design teams, content experts, and Lean operations support to assure that the right decisions are carried forward in each design proposal. Base each decision on a set of team-formulated "guiding principles" or "enterprise values" that signify the organization’s mission, values, and strategy, and the project’s purpose.

Virginia Mason Hospital in Seattle implemented this process when it was considering a major addition. The challenge was to design Lean and build Lean. Already a few years into its Lean journey, the hospital could visualize the advantages of this approach, so it created a Lean project-delivery method that focused on rational decision-making. Standard work was developed for team participation, accountability, and decision-making authority. Standard work was also implemented for Production Preparation Process (3P), design charrettes, and project meetings. In addition to the "enterprise values," an "umbrella" IDP agreement was developed to guide the owner, architect, and contractor through the project. Diagrammatic examples of the planning process and team organization accompany this text.

Implement experience-based design—the "voice of the customer"

More than a poll, an interview, or a focus group, experience-based design captures the patient’s experience; patients (and caregivers) tell their stories to the architects and designers developing new spaces. Allowing this information to guide design enables healthcare organizations to work in partnership with patients to create new and improved processes, and enhance space use.

Evidence-based design

From its roots in The Center for Health Design’s Pebble Project, evidence-based design continues to inspire knowledge capture and innovation. Current best evidence from the organization (along with industry research and practice validation) is used in a critical thinking environment to reach the most effective design solution.

Employ Lean design tools

The gains from applying Lean observation, analysis, and design tools cannot be underestimated. Lean design takes evidence-based design to a higher level. Because Lean design is based on data and direct observation, it uses informed trial and error with testing and simulation, working models, and full-size mock-ups. The ideal venue for beginning Lean design is the 3P workshop, a highly facilitated, week-long event. This is the process through which a project team reinvents its business delivery model prior to launching a new product or building new facilities. It assures that the correct building program has been evaluated and approved by the organization.

Prior to beginning programming, one Northwest-based hospital system conducts at least one 3P event for every facilities improvement project. Data collection, including patient volumes, time studies, utilization review, videos, and much more, begins four weeks prior to the 3P event. The 3P team uses the data to document existing processes, find waste, and design new processes. Often the new process design leads to conceptual space design.

When Virginia Mason Hospital used 3P events and experience-based design focus groups to design a prototype clinic model based on patient flow, it evaluated the impact of such unique features as kiosk check-in, no waiting rooms, GPS patient tracking (within the facility), on-stage and off-stage zones, no provider offices, and team "touchdown" workstations. The resulting design significantly decreased patient lead time and operating costs, while increasing patient volume and patient satisfaction. This is just one example of process redesign leading to a new approach in healthcare design. 

Set-based design

The medical planning process usually consists of a number of initial concepts, which are then narrowed down to one and further developed until approval. A creative evolution of this process is "concurrent set-based design," developed originally for manufacturing prototypes (and adapted from Sobek, Ward & Liker). The set-based process has been successfully adapted to serve as a Lean design tool. Key process steps include:

• Multiple concepts are developed in charrettes using an integrated design process model;

• An "evaluation gate" is used to select the concept(s) that align with the project’s guiding principles;

• The concept(s) with the highest probability for success a
re advanced and refined in subsequent design charrettes;

• After clearing a number of "gates," the final integrated design is selected and documented; and

• A significant value of this process is that knowledge gained during design is not lost. If a potential solution is determined not to be viable, the team can look to prior design concepts for a solution.

Concurrent set-based design process

• Simultaneously develop multiple concept solutions.

• Review and evaluate each concept based on project criteria.

• Advance the most successful concept.

• Refine final choice for design integration.

• Retain ruled-out choices as alternates.

Recently, a medical center in the Northwest applied this approach when planning a major building addition to its existing campus. A vital connection scheme between buildings was proposed, along with a few less-desirable options. When the construction and engineering teams investigated the existing concrete structure and plumbing lines, a number of major conflicts were identified. The connection option appeared doomed. With no feasible solution in sight, the team revisited the previous concepts and discovered that the scheme initially perceived to be too expensive was actually far more cost-effective, and even provided an outstanding opportunity for company branding by using a large expanse of window wall.

With the scheduled implementation of healthcare reform, the healthcare industry already is changing radically. It is no longer business as usual. Organizations are searching for solutions to improve processes filled with waste. They are looking for ways to streamline their operations and reduce costs. They may need to remodel or add space, but this will only come after a thorough review of their current processes and facilities. The use of Lean design methods can be an important part of the solution. HCD

Doug Grove is a senior medical planner with CollinsWoerman Architects in Seattle. He is a registered architect, and a certified Lean leader, who trained in the United States and Japan. For more information, please visit www.collinswoerman.com or www.virginiamason.org.