The Lee Health System in Ft. Myers, Fla., which operates four hospitals and 11 clinics, had plans to expand with a new outpatient facility in Cape Coral, Fla., that would make care more convenient for patients and expand the organization’s market share. However, on previous building projects, Lee Health experienced cost overruns and missed construction deadlines; in addition, after move-in, significant rework was required. For this new project, Surfside Clinic, the facilities management team wanted to find a way to break through some long-held paradigms in facility design to avoid repeating that history.

The health system worked with Opus Solutions (Columbia, S.C.), a consultancy focused on quality improvement in healthcare, on a previous renovation project and reached out for assistance on the new 27,400-square-foot clinic to lead the design-build process on the Surfside Clinic. Together, the team used a combination of Lean principles, evidence-based design (EBD), and some “disruptive innovation” to design the new two-story facility, which opened in August 2015 featuring imaging, breast health, and a lab draw station on the first floor, and primary care, including internal and family medicine, on the second floor.


The design process

Traditional facility design is a top-down process with the architect circulating a concept or blueprint for a new facility that’s followed by rounds of comments and changes. This model can include certain assumptions, such as “bigger is better” or “staff will need to adjust to the new facility after they move in,” and accepts construction delays and change orders as part of the normal process. Most important, traditional wisdom relies on norms or standards that can inhibit innovation and import old inefficiencies into new facilities. Long-held standards for outpatient clinics include the idea that physicians need individual offices, teaming for providers is difficult, patient wait times are part of the process, and that three exam rooms per provider are needed to keep physicians busy.

On the Surfside project, Opus Solutions took a different approach and turned to the providers and staff who operate clinical departments to provide expertise to shape the design and clinic’s future operations. The design process occurred in three phases—Training, Macro Design Workshop, and Micro Workshop—and representatives from all functional areas of the clinic, facilities, and the architect were present during the entire process.

Phase 1: Training: Before clinicians are asked to make design recommendations, it’s vital that they understand the principles of Lean and EBD. Lean concepts such as value streams—for example, moving a patient or piece of equipment from one value-added step to another with no wait times or barriers—were introduced, as well as the importance of using data or evidence to influence design. During the training, the facilitator challenged traditional design delivery through critical questioning and encouraged collaboration to identify alternative methods.

Phase 2: Macro Design Workshop: The goal of this one-week intensive session was to produce a building blueprint that’s done right the first time. Representatives including clinical staff and facility managers designed their respective departments on paper and presented layouts to the entire team to get feedback on function, potential bottlenecks, and integration within the flow of the entire facility. After each presentation, team members provided critical feedback, asked questions, and proposed innovations for greater efficiency. Up to seven iterations for each department were presented until the team was convinced they had the most efficient design.

Outcomes from this process produced some breakthrough results. For example, in traditional clinic operations, data shows that patients can spend 30-40 percent of an office visit waiting. The facilitator challenged the team by asking, “What would happen if we removed most of the wait time between patient arrival and patient rooming and reduced wait time in the room to zero?” To achieve this, the team decided to reduce the size of the waiting room to accommodate family members and have patients escorted directly to a room by a medical assistant to immediately begin the clinical work-up, resulting in a 25 percent decrease in waiting room space.

Phase 3: Micro Design Workshop: The final step was a one-week session to test macro design assumptions using cardboard mock-ups of all departments. Team members included exact details, down to the computer terminals, devices, and supplies in each workstation, and tested walk patterns and cycle times to assure providers wouldn’t have to leave their stations to search for tools and supplies.

Actual patient visits were simulated from arrival to discharge to help ensure that move-in would be seamless and that minimal rework would be necessary after opening. Process cycle times were measured and documented to validate capacity and flow assumptions during this phase. Any lingering issues dealing with wait times, bottlenecks, and tool placement surfaced here and were addressed, too.


The results

In previous clinic projects the design process took up to two months with multiple rework loops and the design-build cycle time was 12 months or more. Using these three stages, the Surfside Clinic team reduced the design process to three weeks and the build time to only seven months. In addition, there were no cost overruns or change orders on the project. The key elements for success included having all stakeholders present for each phase, training staff in EBD and Lean concepts, and conducting real-time simulation.

Steve Friedland is a managing partner at Opus Solutions, LLC. He can be reached at