Integrating Lean Process Improvement in Healthcare
When clients hire TRO Jung|Brannen (TROJB) to design a renovation or new facility, they expect the end result to be not only new space, but space that improves care and helps them leap beyond their competition. Improved healthcare can be achieved through a variety of measures—higher outcomes; lower costs; higher patient, family, and staff satisfaction; more comprehensive service lines; or more efficient operations. Typically, all of these parameters contribute to a client’s definition of improvement, and hence all are relevant in determining a project’s success.
Understanding how healthcare facilities operate is essential for designers. In fact, since many healthcare designers work for multiple clients across wide geographic areas, TROJB develops a knowledge base of current processes and emerging trends that is valuable to clients. The firm brings “what’s out there” to individual clients; helps them evaluate alternative ways of providing care; and designs a facility that optimizes the best practice operations they choose to adopt, consonant with their unique culture.
Building a new project is a natural opportunity for a client to explore what they do well and where they can improve. As we facilitate the design process, we work with our clients to define their care delivery model and back-of-house operations, as each of these systems influence the design.
In order to ensure that the operational assumptions underlying a design are developed in a clear, strategic way, TROJB has developed a comprehensive array of Lean process improvement tools that are utilized throughout the design process.
Some of these tools are integral to our basic services, others are specialty events. We can facilitate many of them in-house through our Lean and Six Sigma trained staff, while others we facilitate in conjunction with our client’s process improvement departments or independent consultants. We work with each client to determine which Lean offerings are most appropriate for their project based on scope, schedule, and level of staff interaction.
1. Establish vision and scope. We adapt a Lean point of view in establishing the project vision, scope, and critical success factors. This requires collecting and analyzing existing data, benchmarks, and facility projections to establish the project definition and developing a function-based, rather than department-based, program.
2. Lean 2P/3P events. We define and facilitate Lean 2P/3P events to model operations in the proposed facility. This includes Lean training for the principal clinical user groups; facility-wide flow diagrams for patients, staff, information, supplies, and waste; 2-D layout exercises to test options; PFMEA (Process Failure Mode Effects Analysis) of proposed solutions; and real-time simulations of 3-D mock-ups of key process areas based on anticipated workflow drawn from relevant data.
3. Target events. We facilitate focused target events to address specific operational concerns. These may be rapid improvement events, current-versus-future-state value stream mapping exercises, or “card trick” simulations of proposed layouts.
4. Integrate with global Lean initiatives. The services outlined above are relevant to a particular design project. Often, clients are also engaged in developing system-wide approaches to Lean process improvement. There may be system-wide initiatives that we want to incorporate in the new facility, or opportunities developed for the new facility may merit wider implementation. In either direction, TROJB interfaces with in-house or independent Lean consultants to incorporate system-wide Lean initiatives.
Establish vision and scope
Establishing the project vision and scope, as well as determining critical success targets, involves one or more group visioning sessions, data collection, benchmark research, and synthesizing the results to create a unique project vision.
The project vision should be a simple statement of the project’s overarching goals—the elevator speech. Sculpting the various objectives of a project into a single statement can be challenging, but the more clearly everyone on a team can articulate the same message, the easier it is to sustain project focus. A project whose goal is to increase market share will be different from a project that will support the Planetree philosophy, which will be different from a project that is a code upgrade. All three components may be addressed at some level, but the primary focus—the vision—will be the predominant driver of the final design.
Since one hallmark of Lean process improvement is that you cannot change what you cannot measure, this process is data-driven. We work with our clients to obtain and review data about current market share and demographic change. We collect existing parameters surrounding patient care, which might include wait times before first appointment, wait time to get into a specific treatment queue, wait time when arriving at an appointment, durations of specific treatments, and so on.
We focus on waiting-related data because waiting is pure waste. Waiting never adds value, it often adds cost, and it adversely affects satisfaction.
Patient satisfaction measures, such as Press-Ganey scores or other satisfaction benchmarks, are key information. We also solicit “cross-system” data to understand efficiencies and bottlenecks within the facility. This can include lab or pharmacy turnaround times, consultation or transport wait times, supply hand-offs, and waste/clean up times.
We match this data to related national or regional benchmarks to understand how our client’s facility measures against their peers. This comparison is then used to form the basis of the critical success targets we establish for the new facility.
Unlike the vision, a project can have many critical success targets. These are specific, measurable parameters that reflect all of the project’s objectives. Critical success targets can be broad (increase market share in cardiac services by 12%) or narrow (no inpatient room more than 20 feet from a staff work area). They can be operational (decrease pharmacy FTE’s by 20% through the use of automated dispensing and robotics) or cultural (locate the wellness and learning center for after-hours community use). The two key aspects of critical success targets are 1) that they support the vision, and 2) that they are achievable.
Unrealistic critical success targets are tempting, but if we use misguided targets to determine project parameters, the project will fail. As an extreme example, consider a hospital with an ED throughput time for non-admitted patients of 240 minutes. In their zeal to be efficient, they might set their critical success target at 60 minutes, well below national benchmarks.
If we then determine the number of treatment spaces needed based on 60-minute throughput, but achieve only 120-minute throughput when the facility opens, the ED will be woefully undersized. Critical success targets should be ambitious, but they have to be achievable.
The vision and the critical success targets influence the program. Programming a project from a Lean perspective requires thinking beyond departmental boundaries to understand functional affiliations. This requires assessing the current departments with an eye towards whether they should be modified or combined to better align with the model of care objectives.
This is best done at a senior administrative and process improvement level, as it is difficult for people operating within an existing departmental structure to embrace change that might alter their position in the hospital. Although Lean process im
provement objectives are always about doing the work more efficiently, and not on downsizing per se, it is important to acknowledge and address job security fears that often accompany discussions of Lean.
Once we have identified the functional relationships that best support the model of care, we assemble user groups that align accordingly. In recent projects we have explored such opportunities as:
- Differentiating sterile/non-sterile supplies at the point of order. Supplies are pre-palleted for their final designation, thereby minimizing breakdown/holding at the loading bay.
- Creating an integrated transport service that can move patients, meals, and supplies, thus having more people available to move specific items at critical periods of the day (patients during morning treatment sessions, meals at noon, etc.).
- Reducing the time for special prescriptions to be administered by expanding the pharmacy communication flow beyond the pharmacy proper, tracking the medication until the patient receives it.
Lean 2P/3P events
Lean 2P (Preparation/Process) and Lean 3P (Production/Preparation/Process) events are significant opportunities to marry design and operations. They involve running operational simulations through the proposed space, ideally at actual scale and under realistic conditions.
The tools we use to establish vision, scope, and benchmark-based critical success targets require a commitment to rigor more than an extraordinary commitment of time. Functional-based programming requires strong executive direction rather extensive clinical input time. However, intensive Lean events require large amounts of staff time.
Not every project will warrant full Lean events. When we outline the design process with a client, we determine the “must have” Lean events, identify “potential” events that may be worth the effort as the design develops, and also identify events not included in the process, so we can seek other, less costly, ways to approximate the value these events might yield.
The ideal Lean 2P/3P event takes several days and up to a week, to implement. It requires broad participation of every stakeholder in the process, a solid background in Lean training, and a large space for running simulations. Cost in terms of staff participation is high, but the benefits can be even higher.
Many Lean concepts are counter-intuitive to traditional modes of working (that batching is inefficient, that less space can make us more efficient, that we should avoid multi-tasking) but the intensive, hands-on experience of a Lean 2P/3P event can help staff embrace these principles, resulting not only in a more efficient layout, but a layout that staff is committed to making work.
A recent Pharmacy 2P event for a large hospital included two days of staff training in Lean concepts, a break of several weeks to gather relevant data, then a full week of process mapping, PFMEA analysis, cut-out diagrams, and simulations. The event took place in a large empty space where we ran scripted simulations based on data of projected demand, filmed the process, reviewed efficiency, and modified the layout accordingly. After seven iterations, we developed a plan that was tighter than anyone initially conceived, but the staff enthusiastically endorsed the solution.
Lean principles are relevant to different healthcare processes in different ways. As a philosophy rooted in manufacturing, Lean has its most direct applications in high-volume, repetitive operations, like pharmacy, lab, and materials handling.
However, it would be wrong to assume that only back-of-the-house functions can be improved by applying Lean principles. The key precepts of standardization—maximizing value, minimizing waste, pull scheduling, and using triggers to stimulate flow—are relevant for every aspect of patient care.
When we design 2P/3P events for patient care settings, our focus is less on scripted simulations enacted in large-scale mockups and more on creating standard processes that can adapt to the many variables encountered in direct care. We then test these processes in mockups of specific rooms or clusters.
An adjunct to Lean 2P/3P events is focused exercises on specific areas of concern, essentially prescriptive rapid improvement events.
Target events identify very specific questions and seek resolution within a single three- to four-hour session in which all stakeholders are represented. Early in design, these events are typically process-mapping exercises, where we identify current state processes, brainstorm their strengths and weaknesses, and develop a future state map that can inform the design.
As the design evolves into a viable plan, target events evolve from informing the design to testing it. “Card trick” simulations are easy and interactive exercises in which we create a set of cards that represent a work day, each card representing one step in a process.
In a patient care area, each patient is represented by a set of cards, one for each step in their process. This is an effective tool for areas like interventional suites, where efficiency depends on smooth patient flow.
We simulate the day by placing the cards on the plan at timed intervals corresponding to how patients occupy the space. For example, as patients move from reception to prep to procedure to PACU, we can measure how many steps are involved, observe where bottlenecks occur, and identify excess capacity.
Computer simulation programs that input the proposed layout and patient data can provide the same information at a much finer grain of detail. However, computer simulations are more expensive and require extensive data input to create an effective simulation. We find that staff responds in a more immediate way to the hands on card trick approach because they are forced to make decisions about the patient as they physically move the card across the plan.
The results of target events often have architectural implications, but just as often they inform the scope of communications systems for the building as we identify points in the process that require triggers and understand how information must move to maintain flow.
Integrate with global Lean initiatives
Our vision statement when working with clients on Lean improvement is, “A Lean process produces a custom product on demand.” That single sentence embraces every Lean concept, from defining value to standard processes to pull scheduling.
When we can deliver a product (medical diagnosis and treatment) tailored to the specific needs of each patient, and deliver it without waiting or waste, we will be Lean.
No healthcare project is an island. It exists in the context of a healthcare system. As such, no matter how Lean we try to make a specific facility, the system can only be as efficient as its weakest link. That is why standard processes across a system are essential to provide the most efficient patient care.
Sometimes we work on projects in systems that have already determined standard processes for aspects of the work, registration perhaps, or EMR, or checklist protocols. When we have these Lean templates in place, our work is easier, because we have established givens that everyone on the team can embrace. There is one less thing to determine.
Alternatively, the work we do to incorporate Lean processes in a new design often becomes standard processes that a system implements beyond the project itself. In either case, we work with the process improvement department or independent consultant to integrate a system-wide view with our project-focused view.
Paul Fallon, RA, LEED AP, EDAC, is a S
enior Associate with TRO Jung|Brannen. For more information, please visit www.trojb.com.