Hospitals seeking to eliminate revenue losses while simultaneously boosting process efficiency and patient care levels are discovering the benefits of Lean design for their clinical and nonclinical departments.

Lean design identifies, locates, and removes operational process waste. When a facility operates under Lean parameters, the patient experience can be streamlined. For example, a patient can visit the doctor, get an X-ray, have it read, receive a diagnosis, and pick up medication from the pharmacy all in one visit, whereas in the past, multiple visits were required before diagnosis and care could be delivered.

Such efficiency may come from centralized check-in kiosks that allow a patient’s personal information to be shared throughout the entire visit, eliminating the repetitive hassle of filling out the same forms for each department. For staff, a reduction in paperwork means they’re freed up to do what they do best: take care of patients.

For the method to be successful, an efficient operational process must be supported by the physical space.

Another example: When patients arrive at a traditional clinic, they might be met by a triage nurse who determines the problem, makes the patient wait in the receiving area for an exam room to open up, and then makes the patient wait some more in the exam room for a doctor to appear.

Patients arriving at a Lean-designed clinic instead may be met by a triage nurse who immediately admits them to an exam room where they are then met by a registration person. After that, the caregiver comes by to assess and diagnose.  

“If we can get rid of patient waiting times in favor of improved throughput, then we make better use of the caregiver’s time,” says Roger Call, director, healthcare architecture and design at Herman Miller Inc. (Greater Grand Rapids, Mich.), president of the AIA Academy of Architecture for Health, and Lean expert. 

Improved Lean supply chains are another boon to the bottom line.

Andrew Wampler, assistant vice president at Mountain States Health Alliance (Johnson City, Tenn.) recalls when Johnson City Medical Center had five nonstandardized, differently keyed supply closets. Two of the closets were located just outside the emergency department, which meant nurses had to leave the sterile ED in order to get to the closets, plus remember which key went to what closet.

His solution involved repurposing a conference room located in the middle of the ED into a standardized supply closet. As a result, the new location improved the focus on the patients while eliminating wasted time, wasted energy, unnecessary closet space, and multiple refilling stops by maintenance staff tasked with stocking the original five closets.

“Lean design is not just how people receive care; it’s really how to attack the delivery of healthcare on the business side of things,” says Andrew Quirk, senior vice president, national director at Skanska (Nashville).


The process
Implementing effective Lean design means architects must understand and be able to clearly communicate both the macro and micro innovation details to a staff hampered by only knowing one design—the facility they currently work in.

“Architects must be extremely specialized and knowledgeable in all the ways care is delivered in other facilities so they can come to the table with several suggestions on how to improve a process,” says Ron Henry, senior vice president, health sector lead at real estate consultant Plante Moran Cresa (Detroit). One way to do this is to whiteboard the facility’s process pinch-points. It may take several sessions to fully map them, but once those challenges are highlighted, “we go into a full series of meetings on how to improve that process,” Henry says.

In addition, architects should “question everything but provide design opportunities or solutions,” says Quirk, who suggests asking whether a diagnostics area can grow as demand increases over time or if the patient rooms are adaptable to new reimbursement demands without the need to make drastic renovation changes, for example.


The challenges
In a perfect world, capital and a set managerial direction would clear the path for implementing Lean design. However, between deferred maintenance, the current trend of purchasing and merging primary care practices, and technology upgrades such as electronic medical records and telemedicine capabilities, many executives are stymied at how to correctly prioritize and deploy their limited capital resources.

“We say, ‘Let’s work on those things we can solve now, but let’s be creative before going to spend a lot of money,’” says Wampler, who points out that hospitals can make any number of Lean improvements without having to build or buy something new. “Sometimes it’s just a revamping of how departments currently work within their silos versus working within a collaborative approach,” he says.

Wampler cites an example where an ED is backed up during the morning because there are no admitting rooms available for new patients until after lunch, when doctors typically complete their discharge paperwork. When these rooms are finally cleared, the staff must clean them all at once before allowing new patients in.

More rooms aren’t necessarily the solution when the problem is departments inadvertently slowing the next one down. Instead, mapping the process flow to determine the necessary adaptations (earlier discharges and staggered room cleaning) will mitigate the problem with a minimum of capital expenditure.

The example also demonstrates a reason that executives should consider Lean innovations before embarking on a large design project: “First, more often than not, the cry for ‘more’ really is a cry for help to fix a broken process,” Quirk says. “Second, waste increases frustration, expenses, and errors; and third, more and bigger space is not usually the answer.”


A management system
While experts agree there’s no perfect journey from Point A to Point B, they do agree that in order for Lean design to be successful, executives must recognize that process issues exist, be open to change, be willing to bring on knowledgeable professionals who offer different ideas, and then embrace these changes for the greater collaborative good.

“You must go at it as a management system and not just as a process improvement system. If it’s a process improvement only, with no leadership endorsement, it will just end up as a fad,” Wampler says.

Gwynneth Anderson is a freelance business writer. She can be reached at