Providers who continue to sit on the fence about adopting Lean processes in their operations can look to the bottom line for evidence of need. This article highlights such problems as wasteful practices, excess inventory, unused capacity, and other factors that Lean operations can help solve. It describes how Lean process can be “designed-in” to the built environment.


The stage is set

As the Affordable Care Act celebrates its one-year anniversary, it is quite evident that with or without the act, healthcare delivery is destined to change. Predictions indicate that without significant change, a continued increase in healthcare spending may drive our economy to insolvency.

The majority of healthcare delivery organizations agree that “doing nothing” is not an option and together they can transform healthcare, and avoid an inevitable catastrophe. Becoming an “accountable care organization” (ACO) is one way to compel them to reinvent their processes. In this way, organizations can drive out waste, improve care, and decrease costs—even with increased demand from the boomer generation and the possibility of more uninsured people.

But how can design of the built environment help to remove waste and reduce the cost of care? Can Lean design drive operational change? To a large degree the answer is “yes,” but not without significant transformation of every healthcare delivery organization. The healthcare delivery infrastructure must change. Most improvement strategists caution that waste will get in the way of any improvement efforts, so the primary tactic is: Remove the waste first.


Operational impact—strategies for immediately reducing healthcare costs

The elimination of waste in current practice will go a long way to cut healthcare spending. A number of healthcare research organizations have identified specific areas where waste is most prevalent. Many of these wastes are being targeted by healthcare reform:

  • Administrative inefficiencies have long been recognized as a huge source of waste. Every step, from documenting patient records to billing multiple insurance providers, is laden with the waste of variation. Administrative costs consume nearly one-third of each dollar spent in healthcare. Implementing standard work will also lead to reduced space demand.
  • Clinical inefficiencies are a significant source of waste in both operational and facilities terms. Lack of efficient scheduling practices and poor resource coordination have led to inappropriate equipment utilization (for example, expensive imaging and surgical robotics) and low facilities utilization (such as idle ORs and exam rooms), resulting in operational inefficiencies. Other sources of waste include overutilization of patient testing, intensive care services, and hospitalizations.
  • Avoidable errors can lead to increased utilization of hospital services, such as unnecessary admissions, extended stays, and readmissions. Incomplete drug reconciliation and adverse drug effects are other sources of errors.
  • Care coordination is vital to cost containment. The lack of care coordination results in more ED visits, hospitalizations, and medical errors. Reasons for this condition range from missing or incomplete medical records to poorly documented handoffs to inappropriate tests, treatments, or drugs administered.
  • Unnecessary use of services contributes to nearly half the waste identified in healthcare. These include “defensive” diagnostics, like lab tests or imaging ordered to limit malpractice exposure. They also include inappropriate use of higher cost diagnostic and treatment procedures not warranted by the patient’s condition or by established treatment protocols.
  • Lack of preventive healthcare can lead to the use of more expensive and avoidable services, such as ED visits and hospitalization. Timely access to affordable, quality outpatient care may lessen the need for emergency and acute care. Excessive and unhealthy lifestyle choices only exacerbate the situation.
  • Estimates vary, but fraud and system abuse waste 3 to 10% of our healthcare dollar. These practices include billing for services not provided, cost misrepresentation, and referral kickbacks. 

In  2009, it was estimated that the total of all this waste prevented more than $700 billion worth of healthcare from reaching those in need. 


Survival strategy: Remove the waste

Removing waste wherever it’s observed is not an easy task. For many caregivers, most types of waste are accepted as a necessary evil. Employing a Lean design approach will enable your healthcare client to significantly reduce or eliminate waste in their processes: 

  • Defects. Stop repeating mistakes that lessen the patient’s experience. We must “mistake-proof” our designs to make patient care mistake-proof, such as placing handwashing facilities in clear sight as one enters the exam room.
  • Waiting. Facility design can enable organizational change to see patients “in-flow” (the one-by-one Lean approach). Not only will this improve patient satisfaction, but it will prepare the organization for expected patient volume increases with minimal facilities expansion. Universal exam rooms or procedure rooms must replace “my exam room” or “my OR.”
  • Communication. Absence of standards or standard work, no visual controls, ineffective teamwork, and inadequate documentation all lead to defects. Effective communication requires and promotes an environment designed for interaction and collaboration. Our designs must not only incorporate a robust technology infrastructure, but promote visual control methods and logical wayfinding.
  • Inventory. Every care provider must have the right equipment and supplies, in the right amount, in the right place, and at the right time. Facility design can enable a reliable system for obtaining the right supplies.
  • Motion. Standard work, working in-flow, adequate training, and appropriate communication all lead to less running around and more time caring for the patient. Why not bring all care to the patient? 

The bottom line for designers is to integrate the design process with operational improvement. Transformed healthcare delivery organizations leverage their design relationships to remove waste, improve operations, and implement strategic measures.


Effect on design

In planning for the future, designers should consider the impact technology will have on patient experience and patient care. For example, will primary care veer toward the medical home concept? Will there be less need for specialty clinics? Will increased use of phone and email consultations decrease the need for exam rooms?  Will waiting rooms become extinct? Will clinic visits become more acute and turn exam rooms into treatment rooms?

Lean design is not truly Lean unless it follows Lean operations. Transformed healthcare organizations will have adopted Lean principles in re-engineering their care delivery model. Can Lean desig
n drive organizational change? We can map flow and design-in flow. We can test flow with mock-ups. We can plan for flexibility and adaptability.

Lean is the methodology that holds the most promise to reform healthcare for the benefit of all patients: 

  • Cost. If the Affordable Care Act survives the many challenges brought forth, healthcare organizations will see a considerable increase in demand for their services—but receive less reimbursement from the government.
  • Patient. Lean is thoroughly analyzing the process of healthcare delivery from the patient’s perspective.
  • Change. Lean accelerates organizational change to remove waste and attain zero defects, thereby improving patient safety, lead time reduction, quality of care, and patient satisfaction.


Lead the effort: Facilitate guiding principles development

Establishing guiding principles will help organizations better facilitate decision-making. All parties agree to align their priorities with principles such as: 

  • Deliver an extraordinary patient experience;
  • Embrace Lean processes and methods;
  • Build-in future flexibility and adaptability;
  • Provide an exceptional staff experience;
  • Adopt integrated project delivery; and
  • Pursue sustainable design.


Lead the effort: Help to implement a Lean project planning process

Integrating operational and facilities planning with a rational decision-making process will produce value-added outcomes: 

  • Teams. Build the appropriate team(s) to provide oversight, accountability, review, approval, guidance, and expertise before design begins. Engage all team members now.
  • Value. Incorporate value as a guiding principle in design. Before beginning design, there must be a clear understanding of program, quality, cost, and schedule.
  • Methods. Employ Lean processes and tools, including concurrent set-based design, BIM virtual construction methods, and integrated project delivery. 

The conclusion: The industry demands that successful healthcare designs must sustain a quantifiable return on investment. This can only be achieved by partnering with healthcare providers to integrate operational and facilities planning together. HCD


Douglas K. Grove is a Senior Medical Planner with CollinsWoerman. He can be reached at