New Voice At The Design Table
Don’t be surprised if there’s an industrial engineer at your next project planning meeting. The continuous improvement specialist—also known as Lean design expert, performance improvement coach, or process improvement consultant—is an increasingly common staff member whose purview is the big picture and whose function is to oust the sacred cows of custom and habit.
Architects are likely to find themselves working alongside these specialists, who challenge user groups and designers alike to streamline processes, trim cumbersome supply-chain links, and maximize the utilization of space. With the support of the hospital C-suite and a big-picture perspective, this professional is in a strong position to shake up the status quo.
Improving the patient and family experience begins with identifying operational procedures and facility design that can reduce extra steps and errors when, for example, clinicians are retrieving supplies or administering medications. The continuous improvement specialist works to improve clinical processes to minimize mix-ups and waste when staff is performing and handing-off tasks or using medical equipment.
At the design table, these specialists serve as the voice of hospital leadership in identifying goals and priorities for improving the delivery of care. They understand how departments work, are privy to ongoing and imminent changes to the current system of caregiving, and can communicate that to design professionals. They challenge user groups about better ways of delivering care and drive change within the hospital by getting others to adopt new standards, procedures, and methods. Their actions improve the alignment between the building design and operational use upon occupancy to better meet the project’s overall goals and objectives.
A couple recent case studies illustrate the benefit of this new collaboration.
North Shore Long Island Jewish Health System, New Hyde Park, N.Y.
Brian Belpanno is the senior director of hospital operations at Cohen Children’s Medical Center in the North Shore-LIJ Health System. With an undergraduate degree in industrial engineering and an MBA, Belpanno’s career has always involved jobs where he optimized processes in order to “improve the quality, reduce the expense, and improve the efficiency” of a business, he says.
“My role, besides ensuring that the project is on time and on budget, is to look at the plans and be the liaison between the end user—a doctor or nurse—and the architect and construction group. Here’s a simple example: Nurses have to go into patient rooms to deliver medications and supplies. So if an architect tucks a supply room far away from patient rooms, the nurse will have to walk farther. Nobody wants that. My job is to understand the ramifications of design on personnel,” he says.
A more complicated example from Cohen Children’s Medical Center concerns a new pediatric MRI that opened in September 2014. Belpanno explains, “In pediatrics, when you perform an MRI, patients are often sedated. Kids don’t want to sit still and you can’t do an MRI if the person isn’t sitting still. But if a patient is in the process of being sedated within the MRI room, it means that the machine isn’t running. Downtime is a loss of revenue. So, near the MRI, we needed to have a room or a bay in which patients can be prepped, and afterwards to recover from the sedation. So the question is, if I have two MRIs, how many of these adjacent prep rooms do I need?”
Using a simulation queuing model, EwingCole worked with Belpanno to determine how long it takes to perform a scan, how many MRI scans are completed in one day, how many of those scans required sedation, and what is the duration. The queuing model revealed how many adjacent sedation rooms were required to optimize the use of the machines.
The logistics of getting medicine from the pharmacy up to patients also merited scrutiny, resulting in a pharmacy automation that regulated flow by using a device called a “box picker.” “It stores all the boxes of drugs that come in, so you type in what you want and it brings that box to you. Then the drug is measured and delivered to the patient floor. It makes no sense to have pharmacists rooting around in storage boxes to find two tabs of aspirin,” Belpanno says.
In the end, the space saved by adopting the box picker allowed the hospital to redesign the retail areas of the pharmacy for more convenient public access.
Belpanno also stresses the importance of metrics to measure the effectiveness of any given design solution, including collecting pre-project and post-project data to compare. “My role really is to take the data—how many steps, how much time, how many procedures—and show people how the math can be improved by rethinking and redesigning spaces. When it’s done you should take the same measurements to confirm that it was worth the expense.”
Lancaster General Hospital, Lancaster, Pa.
Wendy Fitts is the director of performance improvement at Lancaster General. A nurse for 33 years, 25 in the ED, Fitts earned a Lean Six Sigma Black Belt from Villanova University and is the head of the hospital’s quality department.
She says data collection was the key to designing change at Lancaster General. “Before we ever agreed to redesign the ED, our performance improvement coaches looked at several years’ worth of data. When do patients arrive? How much time do they spend in the waiting area? When does the doctor get to their bedside? When do they get out the door? We looked at busy and slow times, weekends and holidays to get a complete picture,” she says. The results were revelatory, pointing to a direct design path.
“Interior designers may at first see an expansive waiting room as a show place for furniture and finishes,” Fitts says. “But one of the things that the clinical staff brought to our attention was a rather frustrating procedure in the ED that caused us to rethink how we utilize that space. People would enter the waiting room and register. Then go to a seat. Then they would come up and go to triage. Then go back to their seat. In the patient’s mind, he’s never moving forward until he gets back behind the magic wall.”
In the new design, patients will always move closer to care. After registering in the waiting room, they will be called into a smaller, adjacent triage room, and then escorted to an examination room. The process may still take a long time, but with the new design of perceived advancement, patients express less frustration. The size of the original waiting room may be reduced by half.
Fitts says, “One of the principles of Lean is value to the customer. What does the patient want? Not a big waiting room. He needs to see the doctor, get his treatment, and get back to his life. The waiting room is almost a defect to that.”
Charged with facilitating projects that span clinical and operational areas, the continuous improvement specialist improves efficiency, effectiveness, and productivity while maintaining positive relationships on both sides of the fence. Architects and interior designers can be the specialist’s greatest allies at the design table. “Architects get it,” Belpanno says. “They understand the need for work flow and efficiency. Where it gets challenging
is keeping costs down as well as designing new systems. How do I do both? The answer to that is ROI, where the return is the health of our patients.”
Designers who recognize the specialists’ priorities will not be surprised when they challenge accepted procedures in a facilities meeting, even those of the design team. The outsider shaking up the status quo used to be the architect. In many hospitals today, the new outsider is inside.
Leslie Kipps, AIA, LEED AP, EDAC is a healthcare architect at EwingCole in Philadelphia. She can be reached at firstname.lastname@example.org.