The Architect in All of Us

For Flad Architects, building a new emergency department (ED) for the staff of Mercy Medical Center–North Iowa meant building with the staff. Working within a Lean 3P quality system and utilizing a large-scale kaizen event, Mercy and Flad gathered a team of hospital employees and other stakeholders to design and build a full-scale model of the new ED.

To hear them tell it, the team of Flad Architects in conjunction with the local firm of Bergland & Cram Architects was on hand to establish parameters, facilitate the process, and provide the expertise to translate a model into an operational, code- and budget-compliant space. But the design itself? That came not from the architects but from the nurses, doctors, and other Mercy employees.

It’s not uncommon for a construction project to begin with a box. That box isn’t normally made of just cardboard. And architects generally are the ones developing a design, presumably in an office—maybe at a drafting table or certainly at a computer—after a series of tours, meetings, and interviews.

Not so for Mercy Medical Center–North Iowa. Its new 25,000-square-foot emergency department was designed in a warehouse, and the people conjuring up the plan were doctors, nurses, EMTs, pastors, and custodians—seemingly everyone but an architect. 

It may sound backward to those who aren’t familiar with Lean 3P. Lean is both an operational philosophy and management system modeled after the Toyota Production System. Businesses espouse it to drive efficiency and eliminate waste. Already widespread in manufacturing, the Lean approach is growing more common in the construction and healthcare industries, particularly as the latter faces shrinking margins, skyrocketing costs, and increasing regulation.

Lean is multifaceted and realized through a variety of tools, exercises, and principles. One of those is 3P. Here the three Ps refer to people, preparation, and process; although, different approaches might have a slightly different set of Ps. For example, some skip the preparation and focus on product. Regardless, the three Ps remain constant within an organization’s Lean framework, and companies use 3P to identify and correct weaknesses in all facets of operation and to cultivate employee participation in seeking efficiency. This employee engagement is considered key to developing a culture of continuous improvement, one of the fundamental components of a Lean methodology.

Mercy adopted the Lean quality system in 2006 as the framework for how it would do business. It also espoused an organization-wide commitment to process excellence. With these two ideologies working in concert, it quickly became clear that there were inefficiencies in the emergency department and that the space itself was chief among them.

More specifically, the old ED was somewhat crowded and lacked privacy. Doctors, patients, and family members all utilized the same central double-loaded corridor. The 14 rooms were routinely overtaxed, which meant patient waits were unnecessarily long. Supply storage was inconsistent, so nurses could work with varying degrees of ease depending on where they were treating patients.

Nurses frequently walked the expanse of the ED to retrieve suture kits, IV equipment, or other supplies. There was little consistency room to room. The inadequate space was taking a toll on all the employees, not just the nurses.

“We had good staff and technology, but a nonfunctional ED,” says Jim FitzPatrick, who was then the medical center’s CEO. “The reality is that we were at a point … when we couldn’t ask people to spin faster. A lot of well-meaning healthcare organizations would just have people work harder and harder and harder. We couldn’t do that anymore. There comes a point when healthcare organizations have to fix the processes and the space.”

Fully dedicated to operating within Lean 3P, FitzPatrick insisted on a design and construction approach not simply consistent with it, but that instead was driven by it.