When it comes to hospital operations, Lean is old news. Healthcare systems across the country have already begun successfully adopting Lean principles to become more efficient and help shave dollars from the continuously rising costs of delivering care.
However, for new building projects, owners are starting to look beyond designing facilities to support a Lean business and toward gaining those same kinds of efficiencies in the overall construction process. And considering the large, complex nature of hospitals, the healthcare industry is an excellent area in which to begin exploring Lean possibilities born from the Toyota Production System.
One example of this can be found in the partnership of Sutter Health, California Pacific Medical Center (CPMC), architect SmithGroupJJR, and general contractor HerreroBoldt, which together are building the Cathedral Hill Hospital, a 16-story, 555-bed facility in downtown San Francisco.
The team agreed to an integrated form of agreement (IFOA), a type of integrated project delivery (IPD) contract that was written by Sutter and the Lean Construction Institute specifically for this project to reinforce collaboration more than a standard IPD contract. One of the primary differences between the two is the way in which the contract is set up so that all members share in risk and reward, with 25% of each party’s profit placed in an at-risk pool.
The pool is paid out to the team if the project comes in at equal to the estimated maximum price (EMP—similar to guaranteed maximum price, or GMP). However, if the building costs more than the EMP, this money goes back to the owner.
Due to new technology such as BIM and the IFOA, the team was able to collaborate from the beginning of the design process while using the spirit of kaizen, or continuous improvement, to optimize the process.
Getting everyone together
To facilitate collaboration between team members from all areas of the production process, Toyota implemented the obeya, or Big Room, to enhance the concept of a cross-functional team. Sutter is employing this concept on the Cathedral Hill project. Almost the entire team is located on one floor of a building, creating a rare collocation opportunity that has proven to be invaluable to communication between team members.
In addition to collocation, representatives from all trades involved in the project team meet together weekly in a large, centralized room that the team refers to as their own Big Room to discuss the status of the project. At these meetings, each member is encouraged to actively participate, supporting a thorough design process through the cross-pollination of trades.
The obeya allows more time to be spent in short bursts of communication rather than long meetings. This saves an immense amount of time normally dedicated to meeting planning and preparation. It also reduces the amount of emails sent between team members, helping to prevent important correspondence from getting lost in the shuffle. The obeya concept is crucial to Lean construction, and this case of collocation has transformed team dynamics and significantly improved production levels.
Keeping the client involved
Another Lean tool integral to the success of the IFOA in the Cathedral Hill project is Target Value Design (TVD), which refers to designing to a specific estimate rather than estimating based on design. TVD proposes that a cross-functional team be involved during the initial stages of the design process, allowing the designer to develop an affordable, buildable design, while design options are carried forward as alternatives with price tags to be available later in the construction process.
All trades are encouraged to explore innovative solutions that save money without compromising design intent. The project team must work closely with the client to agree on the target value. In the Cathedral Hill project, Sutter has several representatives who are constantly involved in the TVD process and attend all