In this age of super-size budget reductions and bariatric-size facility expansions, hospitals are increasingly looking to Lean processes. These processes don't address weight loss, but instead seek to create value through greater efficiencies and less waste in all areas of management—including facility design.

“Lean” processes have arrived just in time. In the foreseeable future, payers will not be increasing payments, even as costs continue to rise—in short, the squeeze is on. Gary Kaplan, MD, CEO of Virginia Mason Medical Center, has succinctly stated the problem and the solution: “There is enough money in healthcare, but so much waste does not allow value to be realized.” Doing more with less by eliminating waste is what the concept called Lean is all about.

The Lean Construction Institute (LCI) has researched lessons learned from the highly successful Toyota Manufacturing Lean Management processes and applied them to the design and construction of buildings in the United States and worldwide. (For examples, see “Design Teamwork From Day One” by Bonnie Walker, AIA, Healthcare Design, July 2006, p. 46, and “Assembly Line Efficiency” by Jason Stahl, Healthcare Design, May 2006, p. 78.) This adaptation is progressing rapidly, but not without difficulties. The difficulties lie not within the principles behind the processes, but rather in how to successfully apply them to achieving three totally different goals:

  1. Production of a repetitive product, such as a car.

  2. Production of a single product, such as a hospital.

  3. Provision of a service, such as an appendectomy.

The likelihood of success of being able to directly apply Toyota's system diminishes from A through C because of a critical element—the customer:

  • In A, the customer is not directly involved in the product production.

  • In B, the customer is only tangentially involved in product delivery.

  • In C, the customer is an indispensable participant in the delivery of the service.

In B, the application of Toyota processes to the construction of buildings is being successfully refined by systems pioneers such as Glenn Ballard, PhD, and Greg Howell, PE, in their development of the Lean Project Delivery System, or Lean Process. This seeks to create project value via elimination of waste, reduction of errors, creation of deeply collaborative teams, use of clear and reliable communications, global optimization rather than improvement piece by piece, and continuous improvement using internal feedback.

In C, the application of the Toyota process to the delivery of services is being pioneered by forward-thinking leaders such as Dave Chambers, Director, Planning Architecture and Design, Sutter Health; the aforementioned Dr. Kaplan; and John Toussaint, MD, CEO of ThedaCare. These leaders have taken bold steps toward reengineering the management of hospital operations to align with Lean Management principles, and they've obtained remarkable results. For example, Virginia Mason Medical Center's application of Lean to designing GI/Endoscopic services resulted in an annual net margin increase of $2.1 million.

These leaders have learned that changing process is successful only by changing behaviors. A realigned working environment will not succeed without staff support for the process involved. Establishing a clear vision of what is being done, and how it is being done, is necessary to gain staff acceptance. Without staff support, the critical participant in the delivery of services—the customer—will not be able to participate effectively in the delivery process.

Good staff vision is exemplified by the workers at the Jelly Belly jelly bean factory in Fairfield, California. If asked what they do, employees don't simply say “We make candy,” but rather, “We help make people happy.”

Sutter Health has become a principal agent for change in the process of designing and constructing hospitals because standards of performance are expected that can only be achieved by a total collaboration of owner, builder and designer, working as a single dedicated team. Toward that goal, Will Lichtig, Esq., an attorney with McDonough Holland & Allen, PC, has constructed a “tri-party” integrated agreement. This document provides for separation of liability, while allowing each team member to become a fully engaged participant in the production of all project services and products. Requiring joint management of risk and disputes, the agreement is the cornerstone of allowing Lean Process principles to work, with a collaborative team of owner, builder, and designer delivering a project having economy, efficiency, and quality of the highest order.

Note that this approach is critically different from the traditional architect/contractor “team” process in which there is no formalized relationship, but only an intent to work collaboratively. Sutter Health's process replaces “intent” with “obligation,” requiring three entities to work as one. The process allows and encourages all participants to safely say “no” to unrealistic or unachievable requests. It also requires all participants to reliably commit to one another. This resulting dynamic creates an environment of confidence and trust, where each participant knows that the commitments given to it are valid, and knows that it will not be pressured to make unreliable promises.

An additional significant aspect of the tri-party agreement is that the owner is obligated to the same rules of conduct as the design and construction entities. Having the owner accept responsibilities for providing clear communications, realistic expectations, participation in constant collaboration, etc., is what makes this process uniquely successful.

The process also avoids the possible dilutions of service that sometimes results from design-build programs in which the design team is an employee or consultant employed by the construction firm instead of the owner. When the architect's first loyalty is to the contractor instead of the owner and the contractor is therefore a communication filter between the architect and owner, the result is a somewhat less than collaborative team. Producing a project using the Lean Project Delivery System requires a high level of trust between the designer and builder.

Such high-functioning designer-builder teams do not evolve spontaneously. It helps, therefore, if there has been a prior working relationship. Also, the team must recognize that, at this point in the development of Lean Project Management, architectural firms are not as advanced as are contractor firms in managing their own businesses in this manner. Never noted for management skills, architects generally are no match for the organizational processes of contractor firms. For these reasons, an owner should not select an architect and a contractor independently of each other and then tell them they must function as a single team. Better to allow teams to self-assemble with firms who have had longstanding successful relationships.

Although the Lean Process, as it is applied to design and construction, is still working through refinement, it is already clearly better than the “Design-Bid-Surprise!” system. It combines the controls that design-build systems offer with loyalties that are better defined and aligned.

Recently Sutter Health engaged the design and construction professions to assist the organization in achieving a goal even greater than an optimized project delivery system. Sutter Health's current projects seek to find new ways to more efficiently deliver healthcare and simultaneously increase care quality and safety. Achieving such a goal will challenge the basic traditional concept of care being delivered incrementally by multiple specialized departments in a sequential process. The result is a new model in which services are delivered in integrated fashion rather than incrementally by closely coupling formerly independent departments into collaborative pods having cross-trained staff and shared equipment and process capabilities. The goal is to optimize the whole rather than just the parts of the patient's case management.

The architectural solutions accommodating this will open new possibilities for operational economies and service opportunities in the delivery of, and more importantly reception of, medical care. Realigned clinical processes will change the flow of care services and the movements of patients, visitors, and staff. How equipment is used and shared, by whom, and where, will also change, as will staffing assignments and job descriptions.

Healthcare institutions have historically been conflicted because their basic hierarchies are notoriously resistant to change, even though every influence bearing upon them—technological, financial, pharmacological, regulatory—demand change. It has been said that agents for change in healthcare are about as popular as a tornado in a trailer park. In this context, we must applaud Sutter Health, Virginia Mason Medical Center, and ThedaCare for actively seeking to accommodate change. The process is no longer focused solely on the “bricks and sticks” being delivered on time and on schedule to create a quality building. The product produced by Lean must be able to provide services by Lean. In the process our hospitals may well evolve from “healthcare” to true “healing care” institutions. HD

Nick Devenney, AIA, ACHA, is President of Devenney Group Ltd., Architects in Phoenix.