Designing for Lean
We have seen amazing technical advancements in medicine in recent years. New drug regimens, minimally invasive surgeries, advanced imaging technologies, and electronic medical records are all increasing healthcare effectiveness. It is also threatening old ways of doing business. With advancing technologies comes increased complexity, and that complexity requires specific knowledge and greater specialization of labor. The primacy of the patient-doctor relationship has given way to an army of healthcare workers, including primary care and specialist physicians, technicians, mid-levels, therapists, and personal care representatives.
Our model of healthcare delivery is insufficient to guide us into the future. In this model, we have relied primarily on our doctor's personal training and knowledge to lead us back to health. As the knowledge base grows beyond the reach of an individual, the customized quality of the patient-provider relationship model does not scale up very well. Henry Ford could build a car in his garage, but it meant nothing to the world until he figured out the concept of the assembly line.
So what will the new model be? Lean management concepts developed in the Japanese auto industry are beginning to have serious influence on our large healthcare systems. This culture of management was born out of an environment of complex technologies and processes embedded in complex organizations-much like our modern day healthcare systems.
Toyota's influence on Lean
The history of Lean is really a story of the evolution of manufacturing techniques over the last 100 years in the United States and Japan. At the turn of the 19th century, about the same time that Henry Ford was building his first automobile factory, Sakichi Toyoda was building weaving looms. He invented a powered loom that would automatically stop whenever a thread broke. This feature saved material and time. The idea grew into a successful enterprise, and from this his son Kiichiro Toyoda started the Toyota Motor Company in 1930.
From that time and into the 1950s, Kiichiro Toyoda made many trips to the United States to observe and learn from Ford's moving assembly line and many other innovations. He realized that his small company and country could not afford the capital outlay and space required for the production equipment and the large inventories that they produced. During these trips he also observed the American supermarket. There, he saw that products were readily available to customers. As soon as a package was removed from the shelf, it was quickly restocked. From these observations, he conceived the idea of just-in-time delivery, also known as a “pull” system. He used these ideas to develop very efficient methods for building cars and trucks.
The rest became history, as Toyota became the world's largest car maker with a solid reputation for cost, quality, and value. The lessons learned beginning with Sakichi Toyoda's loom grew into the universally admired Toyota Production System, an intricately woven web of policies and practices. Key concepts include the ideas of continuous improvement, elimination of waste, and intelligent use of people and machines. Its methods have been adapted by other manufacturing industries across the globe.
Supporting Lean in healthcare design
Healthcare organizations that have embraced Lean recognize the parallels between making cars and providing complicated medical services. Both entail numerous complex processes done repetitively. Moreover, healthcare providers understand that these methods can work only if patient safety and quality of care is their top priority. For these organizations, the relentless self-examination of Lean practice will result in the continuous reinvention and retooling of medical processes and environments.
So how does the design community support this new model of care?
As we began to grapple with the changes that we saw our clients going through, we realized our need to go through the same learning process that they were experiencing. It brought us to this fundamental question: How can we as designers expect to support Lean if we do not practice Lean in our own organization? We began examining our own ways with the simple goal of identifying and eliminating waste wherever possible. We invited outsiders into this process, realizing that those who do the same things over and over again develop blindness to the flaws and inefficiencies of their own work patterns. We approached this process with a willingness to wipe the slate clean and totally change our approach if that was what was required to do it better.
Our first exercise looked at our most basic work process for designing a simple medical clinic tenant space. All of our professional staff participated in a series of work sessions that examined in detail every step of the process. We had never attempted such a detailed self-examination before, and what we discovered was surprising. We found that the biggest source of waste was reworking a design during the late stages of detailed design, most often because our user clients “changed their minds.” As we looked more closely at this phenomenon, we realized that this wasn't the client's problem, but rather ours. We recognized two major flaws in our work process: 1) We did not take enough time to clearly explain the design process to our clients, and 2) We did not spend adequate time and effort identifying exactly who in our client group needed to be involved and when.
Once we were able to define the problem, it was pretty easy to fix. We developed a simple user booklet that described each step of the design process in layman's terms. It described exactly what would happen at each step and what each participant could expect. Our first meeting with a client now focuses on reviewing this booklet, carefully identifying each member of the user team, and when he or she should be involved in the design process. This simple change towards an internal Lean process has resulted in better design solutions, happier clients, and fee budgets that work. It helps us to engage with clients who practice Lean in such a way that they see we speak the same language they do.
Learning from clients' expectations
One of our client organizations has been actively applying Lean concepts for nearly a decade. As they have matured in their own Lean processes, they have also begun to look to their chain of suppliers and consultants to follow suit. As we learned from them, we came to understand that there were many areas where we would need to change our thinking if we were to serve them effectively. When it comes to medical planning, in many ways it is the users who are the planners; we are there to support their effort.
As clinicians, administrators, and support staff come together to scrutinize and reconsider the flows and relationships in a work area, they are the ones who must invent new, more efficient ways. We as designers are there to listen and ask appropriate questions, and when a concept is determined, work to give it physical form. This is a significant change from the architect as space-planning expert. In this new Lean model, we listen more and draw less.
One prominent tool of Lean waste elimination is the value stream analysis. The purpose of this tool is to closely examine each step of a process and evaluate which steps produce value to the customer and which steps simply move the work along but provide no real value. Once this analysis is done, the team rigorously looks for ways to eliminate the non-value-added steps. The traditional architectural services we offered allocated a little less than half of our design time working directly with our clients to define the project. This includes everything from conceptual design down to minute details, such as outlet locations and casework configurations.
By the time we are done with this initial phase, the project is virtually designed in our client's eyes. The rest of our time
is spent in refining and coordinating contract documents for permit review, bidding, and construction. From our client's perspective, there is no real value in this second phase of work; it simply has to be done as an intermediate step to get from a “virtual” project to an “actual” one. As our clients streamline their own processes, it is reasonable for them to question why it takes so long to bring their project to reality.
It is a fair question. This allocation of design effort has generally been accepted by the design profession for years. Even with the advent of CAD, BIM, design/build components, and integrated design and construction services, this time commitment remains the same. We have made it our goal to cut this second phase of design in half so we can spend more of our time working directly with our clients to refine and improve their design solutions.
Our healthcare clients understand that climbing medical costs simply must be contained. They also understand the need to find a new model of care delivery. Our technological advancements must bring us higher value and reduce costs. As our clients move boldly to adapt new ways of wringing inefficiencies out of the system with processes like Lean, the design community must also rise to this challenge. As we engage this challenge, we as designers will need to step carefully, remembering that our credibility is based on practice and that Lean thinking is not limited to our clients alone. Lean is not just a process-it is a management system that has to be embraced internally to be properly applied in the field. HCD
Kent Gregory, AIA, is a founding principal of tgba | architects in Edmunds, Washington. For more information, visit www.tgbarchitects.com. Healthcare Design 2011 January;11(1):32-36