Process-driven design: Virtua Health planning a greenfield campus
Virtua Health is a not-for-profit, multihospital healthcare organization in southern New Jersey with more than 7,200 clinical and administrative personnel and 1,800 physicians as medical staff members. As a part of a quest for excellence, Virtua became a Pebble Project with The Center for Health Design. Virtua has also distinguished itself as one of the first Six Sigma and Lean organizations in healthcare, as an early adopter of clinical and digital technologies, and for its innovative partnership with nationally renowned organizations including GE Healthcare. With Six Sigma as a part of its culture since 1998, it is not surprising that when planning a replacement hospital and ambulatory care center, Virtua purposely invested resources and time to studying process, researching future technology and care delivery trends, and applying Lean to the design process.
The concept that process drives design manifested itself early in Virtua's architect selection process for its new replacement hospital. The Request for Proposal (RFP) was written to test the management engineering expertise of each firm and a Lean workflow challenge was presented to candidates as screening criteria. Respondents were asked to analyze a scenario with simulated patient volume and mix to evaluate the firms' ability to provide campus layouts that minimized travel distances for patients and clinicians while optimizing the patient experience. Factors such as entry points by patient type, major circulation routes, key departmental adjacencies, and expansion capability were examined. The RFP evaluation team included GE Management Engineers who specifically analyzed the responses with regard to travel distances, patient/staff flow, and campus flexibility. Hammel, Green and Abrahamson, Inc. (HGA) was chosen by Virtua as project architects.
The team worked collaboratively to understand current processes and use data to drive decisions around future-state operations and flow.
Future-state planning process
The charge to “design around process” required a nontraditional approach to planning. The architects, management engineers, information technologists, and multidisciplinary user groups used a research-based process with an emphasis on optimal clinical pathways, patient and family experience, and leveraging technology. The team worked collaboratively to understand current processes and use data to drive decisions around future-state operations and flow. Using multiple methods for gathering this data, decisions around architectural plans were grounded in this analysis (figure 1). The future-state planning process was comprised primarily of the following methods:
Future-state operating models
Site visit research
Current state process mapping
Deep Dive sessions
An important part of understanding process is to evaluate the hospital environment from both a staff and patient perspective. Virtua used a photo journal to capture information on how the environment does or does not support the ability to deliver services. To critically evaluate work environments on film and in writing, approximately 60 disposable cameras were distributed to staff along with binders to capture notes. In addition, consenting patients were followed through their care delivery experience to capture on film and in interviews their perceptions of the healthcare environment and how the environment affected his/her experience.
These photo journals identified major themes and space needs that were incorporated into the space programming and schematic design efforts. The expression “a picture is worth a thousand words” rang true with multiple pictures illustrating crowded and cluttered hallways, staff personal belongings stuffed into work areas, and visitors waiting in hallways or overcrowded waiting areas (figure 2).
These perspectives provided additional data for the planning teams to truly understand how staff and patients are affected by the environment in which they work and receive care. During the schematic design phase, Virtua required these data to be implemented within the design. Providing separate pathways for support service functions (i.e., food tray delivery) and visitor flow, accommodating staff personal belongings for every unit through staff lockers rooms, and designating specific spaces for family members to reside while waiting for patients undergoing procedures all affected the design from reviewing the photo journal findings.
Future-state operating models
Photo journals identified major themes and space needs, illustrating crowded and cluttered hallways, staff personal belongings stuffed into work areas, and visitors waiting in hallways or overcrowded waiting areas.
Virtua charged the operations leadership to recommend a desired operational process after reviewing industry journals and best practices. The operational leaders researched future-state operating models for their specific areas (e.g., lab, pharmacy, and patient access) and defined anticipated future processes that they expected to have space implications. Recommendations included the effect that the digital environment has on existing processes and the use of robotics in ancillary areas. Direction for space planning, defining critical adjacencies, and early consensus was achieved through this effort.
Each Program of Excellence leadership team conducted a technology assessment that identified where each Program of Excellence currently resided on the innovation curve in terms of adoption of new technology.
Using resources with the expertise of GE Healthcare, Sg2, the Hammes Company, and HGA, newly constructed “best practice” sites were identified for research and, in some cases, site visits. A multifacility survey was used to evaluate the various hospitals' processes. This research helped to define hospitals with different models of care or services that would merit a site visit. The value of standardization in unit and room layout learned on site visits, as well as studies that link standardization to improved safety in other industries, proved to be valuable and have been applied to the design. Site visits provided external insight and perspective for consideration in the planning process.
Lean concepts were used to develop a process-improvement plan.
Taking into consideration Virtua's overall strategic plan, as well as the specific needs for the replacement hospital, each Program of Excellence leadership team conducted a technology assessment with consultation provided by the healthcare futures company Sg2. This assessment identified where each Program of Excellence currently resided on the innovation curve in terms of adoption of new technology (figure 3). From the assessment, the leadership teams determined where they wanted to be on the technology adoption curve in 10 years.
In collaboration with Sg2, technology roadmaps were developed to define the path for each Program of Excellence that would get them from their current position to the desired position. Specific information derived from the technology roadmaps gave insight into future care delivery which was used to define future patient and clinician flows.
A key takeaway from this analysis for Virtua leaders was the effect that technology will have on transitioning inpatient procedures to outpatient procedures. This information drove the strategy for the development of the ambulatory care center and was used in the sizing analysis for the replacement hospital.
Current-state process mapping
The Virtua management engineer team, along with GE Healthcare management engineers, used Lean concepts that integrated detailed process observations, process mapping, spaghetti analysis, value analysis, and improvement opportunity assessment to develop a process-improvement plan (figure 4). The GE Healthcare management engineers collected base data and charted travel distances around the flow of clinicians, physicians, and patients. This process helped identify different “wastes” (e.g., waiting, queues, transfers, under-utilization) in the existing processes that needed to be addressed. Wastes were categorized into those that were a direct result of systemic failures and current facility design.
As the planning process continued, Virtua took the collected data a step further. Staff interviews were conducted and care providers were shadowed to measure travel distances and frequency of trips (figure 5). With this data, process maps that comprised 80% of the total patient volume were defined (figure 6). Spaghetti diagrams were created to illustrate travel distances and frequency of trips for staff, physicians, and patients (figure 7). These diagrams proved to be an effective visual to understand the pathways of activity performance and pictured the non-value-added trips taken for activities such as “hunting and gathering” supplies in the process of delivering care.
Recommendations included ways to reduce waste in the system from a people, process, technology, and space perspective. The best department design addressed ways to minimize travel distances and maximize access to materials, supplies and information. Designing a work space with the most efficient layout and work flow that supports staff to deliver efficient, high-quality patient care was achieved through this analysis.
Spaghetti diagrams and Lean principles were used to evaluate activities and compare alternative department designs to ensure that process would define space, rather than space defining process. While evaluating activities, questions to consider included, “Will technology enable, eliminate, or improve the activity?” and “Can you change the sequence or route to complete the activity to reduce motion?” To achieve the most efficient layout for operations and care delivery, pros and cons of alternative department designs were shared.
Deep Dive sessions
A series of “Deep Dive sessions” were organized by HGA architects to understand major themes and needs from the baseline analysis and to work with teams to define ideal patient and staff flow. Teams were created and organized by patient type (e.g., pediatric, emergency, and obstetric) and included staff members from a variety of departments, as well as appropriate managers, physicians, management engineers, and IT consultants.
The teams mapped out the ideal patient and clinician flow at the new hospital which paved the path for the architectural planning steps. Future-state Deep Dive sessions provided the ideal voice of the customer's journey with data to support decisions and priorities. The knowledge gained during this process identified key adjacencies for blocking and stacking diagrams, which influenced the overall site layout including optimal entrances, exits, and connection points among inpatient and ambulatory services, and acknowledged the future processes that the design needed to support.
Staff interviews were conducted and care providers were shadowed to measure travel distances and frequency of trips.
While the process-driven design led the team to minimize travel distances for clinicians providing direct patient care, the decentralization of the support areas (i.e., clean supply, medication room) directly affects the work process flow for support departments such as Material Distribution and Pharmacy. As Virtua moves forward in its efforts to operationalize the design, management engineers' expertise will be employed again for simulation studies to help define future work flow and staffing needs. Using a process-driven design approach has produced a more objective and research-oriented way to architectural planning; a culture of continuous improvement and simplifying processes continues.
Process maps that comprised 80% of the total patient volume were defined.
Spaghetti diagrams were created to illustrate travel distances and frequency of trips for staff, physicians, and patients.
As Virtua completes design development and construction gets underway, tremendous work still exists to determine how to operationalize the new design. This work will need to address new processes and new flows, require staffing analysis to support operations, define learning needs, update policies and procedures, and identify financials to support operations and staffing. Virtua will also focus on managing change that all staff will experience with the move to the new campus. The project should be completed in 2010. HD
The Pebble Report focuses on the research efforts and interests of The Center for Health Design's Pebble Project partners, a project that began in 2000 with one provider and has grown to more than 30.