Using Mixed Methods To Build Akron Children's New Pavilion
The team behind the new seven-story Kay Jewelers Pavilion medical tower at Akron Children’s Hospital in Akron, Ohio, didn’t just apply the concepts of Lean and integrated project delivery (IPD) to the project: They wrote the book on it. Really.
In October 2014, Lean Operations, Lean Design, Lean Construction: Building a Lean Hospital Facility was published to offer a view inside delivery of the 368,735-square-foot building that opened to patients in May. “Upon completion of the project, we realized we had a lot to share about how to use Lean and IPD tools and processes to enhance efficiencies and generate savings on a large-scale construction project,” says Grace Wakulchik, vice president of operations and chief operating officer of Akron Children’s. “We hadn’t seen a project that incorporated both Lean and IPD, and we wanted to share our success story with not only other hospitals but anyone undertaking a building project in which these two methodologies could deliver a similar outcome.” (The book is available at Amazon.com.)
The project used a concept created by construction manager The Boldt Co. called integrated Lean project delivery, or ILPD, which maintains the inherently collaborative nature of traditional IPD while adding a keen focus on eliminating waste throughout every project phase. For Akron Children’s, the benefit was a building completed two months ahead of schedule and in under two years, with $60 million shaved off construction costs and a final price tag of $180 million. Plus, it’s 21 percent smaller than originally anticipated, saving $20 million in the final design.
The project was a next logical chapter for the provider in its Lean journey, which began back in 2008, but it started with realizing some of its departments were at capacity and something had to give.
Putting it together
“Our facilities were being used at a level higher than what we’d built those facilities to accommodate,” says William Considine, president and CEO of Akron Children’s. Specifically, the hospital’s ED was designed for about 40,000 visits a year and was seeing 55,000 to 60,000. “To renovate that area would have been a challenge—how do you close an ED to renovate it when you’re seeing that many patients?” he says.
Next, the NICU’s 59 beds were at or over capacity more than 70 days during the course of a year for three consecutive years. “We were going to the state to get permission to put neonatal patients in regular units,” Considine says. The hospital also didn’t offer private NICU rooms, a transition leaders wanted to make to improve the patient and family experience, and a renovation with that kind of census just wasn’t feasible.
Finally, Akron Children’s ORs were swinging between both inpatient and outpatient cases and incredibly busy, and a solution that called for a new dedicated outpatient area to decompress the inpatient OR soon emerged. Meanwhile, considerations for new services, such as high-risk deliveries for moms whose babies require immediate surgery post-delivery, began to surface, as well.
“You put all of that together, and all of a sudden we’re talking about a new building,” Considine says.
To get started, the provider turned to its success with Lean, which started as an effort to become more efficient as an organization and grew into a culture, inspiring the launch of the hospital’s Mark A. Watson Center for Operations Excellence (COE). “If you’re into Lean, you know and hear about integrated project delivery,” Considine says. He hadn’t been involved in an IPD project previously, though, so Wakulchik teamed up with the COE to do some digging, including reaching out to Lean peers across the country such as Seattle Children’s Hospital and ThedaCare.
Making a trip to Washington to visit Seattle Children’s Bellevue Clinic and Surgery Center, built using IPD, Wakulchik says she began realizing the benefits of the delivery method and the inherent efficiencies it brings to the table. “We thought, this is the way to go, this is what we believe in, this is what we’ve talked about since 2008. To turn our back on that and go to a traditional project delivery really didn’t make sense. So we decided to use IPD, which is really a collaborative approach, and also add Lean construction. We went above and beyond what we’d seen our peers do,” she says.
With the decision made, the provider next had to find team members that were up to the task. “That was a key component to our decision tree in terms of who we put around our table to be partners,” Considine says. Taking those seats in the end were national firms Boldt as ILPD construction manager, CBRE Healthcare as on-site project manager, and HKS Inc. as architect and interior designer, and Akron-based Hasenstab Architects Inc. as architect and Welty Building Co. as construction manager.
Making those selections again required bucking tradition, as the provider worked to find a mix of national and local firms that brought the most value by having previous IPD experience or a willingness to learn the process. “So we didn’t use what many folks call the ‘low-bid alternative,’ where you put out your RFQ and your RFP and then take the low bid. For eight months our CFO kept asking when we’re opening bids, and I said, ‘We’re never opening bids. We have a team,’” Wakulchik says.
A five-party agreement was signed between Akron Children’s and Boldt, Welty, Hasenstab, and HKS. “That was also a Lean process in that we spent most of the time in a room with all of us and our attorneys, in two separate sessions, face-to face, where we hammered out most of the contract,” Wakulchik says. Agreeing to share in both risk and reward, the team also saw the contract negotiations as an opportunity to chart its course. “People can tell you they’ve done IPD before, but there are so many different flavors of that, and I think having all those people talk about what the goals are of the project and how we want to achieve those goals helps align expectations and create a team that has a running start,” says Will Lichtig, vice president of business and process development at Boldt (Sacramento, Calif.).
The effort was complete with personality tests to help team members better understand one another as well as a Lean boot camp that included a multiday curriculum for everyone who was going to participate in the program. “It had the collateral benefit of forging the feeling that this was one team, and we were in quest of one major goal. The investment in education on this project was the most significant of any I’ve been involved in,” Lichtig says.
Top to bottom
After that education, the team launched into value-stream mapping and understanding existing conditions in order to improve upon them at the new building, explains Marge Zezulewicz, project manager for Hasenstab Architects (Akron, Ohio). “Paper doll” exercises were performed to determine spatial relationships and adjacencies as well as building stacking. Next up were functional workshops where frontline staff and family members were immersed in weeklong workshops to run through scenario testing of different clinical applications to refine and improve upon them, moving spaces as needed to achieve the best outcomes.
That process was followed by weeklong design workshops where specific locations of items within rooms were determined and scenario testing was performed again. “Probably one of the biggest tools was putting price tags on things and people would say, ‘Oh my gosh, I didn’t realize how much that clock costs. I guess I really don’t need that,’” Zezulewicz says.
However, the team realized that to develop a truly appropriate space, users would eventually need to touch and feel it. “One of the major elements of Lean design is a recognition that most practitioners, hospital clinicians, can’t figure out how these spaces will help them solve their problems unless it’s physical. So throughout the process, we were trying to come up with ways to prototype the space so they could test whether it would solve their problems the way they envisioned. There were significant changes in every space that we touched as result of that prototype,” Lichtig says.
A warehouse about 20 miles from the site was donated to the effort and physical mock-ups were built to scale in cardboard, with a breadth of user participation spanning from surgeons to senior leaders to patient families. “Things the clinicians thought were important, the parents were saying, ‘No, no, no, this is our priority.’ I think that was very eye-opening for operations and sensitivity of what needed to be addressed in design,” Zezulewicz says. “It was phenomenal to watch the transition from ‘I want’ to ‘we need.’”
Wins in the process included realizing that the as-designed observation windows for the NICU unit would be very expensive to construct and allowing clinicians to choose an alternative solution that ended up being better and less expensive. Additionally, the team was able to recognize that a model designed to increase throughput in the OR was completely wrong and adjusted it before construction. Leaders also used the mock-up space to identify immediate needs as well as what areas might be shelled for buildout later, reducing built space by about 30,000 square feet.
From the construction perspective, the approach—especially the user workshops—were especially fruitful. “Oftentimes we as constructors are given a set of blueprints and a chunk of dirt or an existing building and off we go to the races. These workshops made what we were building more personal, because we were interacting with the end users during the design phase,” says Patrick Oaks, project executive with Welty (Akron, Ohio). “It wasn’t just a building anymore; it took on a life of its own.”
Lean was used heavily throughout construction, as well, including prefabrication of the NICU pods, patient room bathrooms, and headwalls. But its less-common uses included using a BIM model to design miles of conduit and duct banks that had to be routed and using the model to assemble them on-site in large sections and crane them into place—making a task expected to take more than 300 hours take only about 100. A drywall and metal stud contractor built exterior wall panels in a warehouse and brought them to the site, as needed, one example of the project’s just-in-time delivery model.
Another major ILPD concept adopted was the idea of a pull production system to better level workflow throughout construction and sync the work of the trades “as if cars in a train, so everyone is moving at the same speed, as opposed to the traditional approach that is rush-hour traffic,” Lichtig says.
So, for example, in the project control room, the strategy for how the project would unfold was depicted down to the daily level of planning required, so everyone knew where the crew would be in the building on a particular day and what would be accomplished by the end of the shift. “It’s a whole production system where you go from huge boulders in the planning process all the way down to grains of sand,” Lichtig says.
The sense of collaboration that the integrated model achieved was evident in construction, as well. In July 2013, as the team was preparing for a massive foundation pour, Akron was hit by a 100-year rain storm, washing a massive amount of material into the excavated site, burying 100 feet of form work, footers, and walls.
“By 3 p.m. the next day, that area was almost ready to pour again,” Oaks says, noting the laborers, carpenters, operating engineers, and everyone in between who pitched in. “Typically, contractors would be looking for a change order in a traditional project delivery environment. In this situation, it was every possible trade discipline you could imagine jumping in and trying to make it right.”
More to come
The resulting facility houses a 75-private-bed NICU; a 20-room ED with 11 fast-track rooms, five behavioral health rooms, a radiology suite, and a three-bed trauma suite; an outpatient surgery with four ORs, eight private pre-op rooms, and 18 recovery rooms; and a two-bed, high-risk labor and delivery department with one critical care room and two connected ORs—just as planned.
But it’s built to respond to just about anything Akron Children’s wants to throw at it.
The Kay Jewelers Pavilion, the first phase of a 25-year master plan, is built for flexibility, too—a goal that drove decisions right from the beginning. For example, Wakulchik says a suggestion was made early on that the NICU rooms didn’t require private bathrooms and they should be cut for a potential savings of $2 million. “If I eliminated bathrooms on two floors of this building, then I have two floors that would be of little use to me if I needed those later on as a post-anesthesia care unit or regular patient rooms,” she says.
To answer that need to adapt, NICU rooms are all standardized and immediately adaptable for a new use. The ED rooms are also consistently sized as opposed to fluctuating square footage based on acuity. Further, the team opted to build as little casework as possible, relying on a heavy use of carts on wheels to reduce the number of renovations that might be required later.
“Considerations that drove the project included how a program might grow within the building and how we would accommodate that, as well as how the campus will ultimately grow. We had to make sure we didn’t make decisions that were really good for solving the immediate problem but created more problems as the master plan was executed,” Lichtig says.
Of the building’s total square footage, 261,300 square feet are occupied and another 95,800 remain undeveloped. But some of that space won’t be empty for long. Akron Children’s is currently adding a dental program with eight operatories and space for two more, an additional 25 beds that can be use
d for NICU or traditional patient rooms, a field treatment center with two ultrasound rooms, and a kitchen expansion.
d for NICU or traditional patient rooms, a field treatment center with two ultrasound rooms, and a kitchen expansion.
And the success of all of it is a direct result of those early planning sessions, close collaboration, and plenty of thought put into exactly how the building would work—and grow. “You can run a project and just use Lean. You can run a project and just use IPD … but what you see, the deliverables and the value that we gleaned from this project, was in combining both of those,” Wakulchik says.
Jennifer Kovacs Silvis is executive editor of Healthcare Design. She can be reached at firstname.lastname@example.org.