Lean design principles stem from the ideals of Lean manufacturing, or the systematic approach to identifying and eliminating waste through continuous improvements in staff and work-process efficiencies. HGA Architects and Engineers embraces Lean as a pre-design methodology for eliminating excess square footage, construction materials, and energy use during the space planning of hospitals, whether the project is new construction or the renovation of an existing department. At its core, Lean’s purpose is to create more value for the end user or customer, with less work and expense on the part of the service provider.

HGA also uses Lean principles during pre-design to add value to the consumer experience by eliminating wasteful aspects of service delivery. That waste might be defined as unnecessary square footage impeding staff efficiency in recovery rooms, or unnecessary steps a caregiver takes to reach a patient in need. Input from hospital employees is essential to predesign and space planning. From administrators to caregivers to support staff, everyone should be involved from the start in the Lean pre-design process to eliminate waste and improve patient satisfaction. 

Integrating evidence-based design (EBD) into the Lean-driven pre-design process increases Lean’s impact. EBD is a research-based approach to healthcare design that focuses on features that improve patient health and healing, wellbeing and safety, and staff efficiency and safety. Such features may include access to natural daylight and views to outdoor gardens in patient rooms, stress-free wayfinding throughout a hospital for patients and family, and task-efficient or even mobile workstations for staff. 

Just as EBD augments the Lean-oriented design process, so does an attention to sustainability further decrease energy use, streamline staff efficiency, and increase patient satisfaction. Windows oriented and glazed to maximize daylight streaming into patient rooms or staff offices not only reduces energy costs but also enhances staff and patient wellbeing. Likewise, hospitals pre-designed using Lean principles to increase efficiency and reduce square footage result in a smaller building footprint, and thus reduced construction and energy costs overall. 

Today, hospital administrators are exploring ways to streamline work processes and reduce unnecessary square footage before beginning construction on a new facility. But applying a three-pronged approach to space planning—one that integrates Lean principles, EBD, and sustainable strategies—is useful at any stage in a building’s lifecycle.


St. Elizabeth Hospital, Appleton, Wisconsin

In 2006, three to four departments across Wisconsin’s Affinity Health System were rated in the top 10% for patient satisfaction. HGA worked with Affinity on space planning for several new construction and renovation projects using the three-pronged approach, to escalate Affinity’s strategic goals for staff efficiency and positive patient outcomes while positioning the company for long-term growth. 

By the second quarter of 2009, more than 30 departments were highly rated in patient satisfaction. In 2009, Affinity was also named one of the top 10 healthcare systems in the United States. Here’s how HGA and Affinity achieved such results at St. Elizabeth Hospital.


Listening to staff and patient concerns

Using a three-pronged approach to pre-designing new construction and renovating existing space, HGA concentrated on five core areas: the ambulatory care center (outpatient diagnosis and treatment), inpatient care units, physician offices, administrative offices, and support services. We engaged a variety of critical stakeholders in the pre-design process, including such design/build professionals as developers, architects, construction managers, and key sub-contractors. They combined their expertise and insights to identify and eliminate unnecessary square footage (and thus the materials, time, and labor that would have been embedded in the construction of this wasted space). 

We also invited former patients, their family members, and caregivers to play a critical role in the pre-design of St. Elizabeth Hospital’s new and renovated spaces. Using EBD research on services healthcare consumers and their families find most valuable, HGA has interviewed more than 3,500 people nationwide on their patient experiences. Our research revealed several key themes:

• The need for privacy;

• Respect as an individual;

• Safety; and

• Individual control over a pleasant healing environment. 

Armed with the knowledge gained from the patients’ experience, HGA began rapid prototyping simulations; mock-up scenarios that place the patient, family member, or caregiver within a potential situation, having them perform their tasks or experience the situation, then asking for their feedback. Through these real-time scenarios, we heard what works and doesn’t; how to streamline situations by reorienting the space and objects in it; where to eliminate waste in time or effort; ways in which to increase patient comfort and safety; and how to reduce stress in patients and families while bettering staff efficiency. 

Moreover, the pre-design process included Affinity personnel, whose experiences and suggestions were addressed during the space planning of the project. For instance, Affinity administrators were asked to address several dozen overarching operational questions. Some of those questions stressed nontraditional approaches to operations, such as outsourcing food service and central sterile processing—decisions that can result in considerable savings in square footage, energy costs, and staffing over more traditional approaches. 

Patient, family, and staff input during the space-planning process helped us “Lean”-out our design, while we also incorporated EBD and sustainable design strategies into our space planning to improve the patient experience and staff efficiency. We also tested our pre-design through benchmarking, peer research, and ongoing rapid prototyping. Through these processes, HGA ensured that all unnecessary waste was eliminated, and new and renovated spaces were right-sized and outfitted with necessary equipment.


Challenging operational paradigms

During the pre-design process, we considered other Lean-driven innovations that would provide inpatient units with portable imaging equipment. HGA’s evidence-based research indicates that for every foot a patient is moved to and from a piece of equipment is actually six times that length as numerous staffers to go to and from that patient. Decisions about portable equipment, of course, depend on volumes, usage, and the aggregate of inpatient unit types. But if orthopedic patients are aggregated on one floor, the Lean decision might be to locate imaging equipment near those patients. 

Such a decision may, in turn, force a new operational paradigm to emerge. A new director of imaging may need to manage people in substations throughout the building instead of within one specific department. Breaking down these traditional departmental operations or silos results in a continuum of care that’s oriented toward the patient. Orientating caregiving to patient streams optimizes care processes for patients and for staff. As a result, patients are discharged earlier and staff workloads are economized.


The three-pronged approach to smart space planning

At St. Elizabeth Hospital, the results of HGA’s three-pronged approach resulted in several other operational innovations and changes in space planning that eliminated waste and improved patient outcomes. HGA designed the outpatient prep/recovery and emergency department immediately adjacent to each other, thus allowing the units to share staff and supply support areas. More importantly, the design allows the two units to flex into each other’s space when daily volumes peak during different times of day. 

In applying the three-pronged approach to space planning during the pre-design phases, Affinity has cut costs in capital, space, and inventory before the Third Phase renovation began. HGA is now collaborating with Affinity on that Third Phase, the expansion of St. Elizabeth Hospital’s Women & Families BirthPlace Unit, Breast Center, Radiology, and Cancer Center. HGA is also renovating Affinity’s power plant to incorporate sustainable design strategies that will reduce energy use by 30%. 

As reimbursable costs for healthcare continue to decline, and patient/consumer expectations continue to rise, hospital administrators continue to seek out innovations in pre-design and space planning that address workflow through the thoughtful planning of the internal spaces, their connections and adjacencies. More efficient flow within and between workspaces and treatment areas can add up to significant savings in construction costs, energy efficiency, and employee productivity. 

Through a three-pronged approach that integrates Lean principles, EBD and sustainable strategies during pre-design and space planning, healthcare facilities can streamline work processes, reduce unnecessary square footage, cut costs, and ensure a more satisfactory patient experience before construction begins.

Scott Lindvall is Vice President at HGA Architects and Engineers, Milwaukee, Wisconsin. For more information, please visit www.HGA.com .