"Leaning Forward", (c) Joyce Durham and Terry Ritchey, Health Facilities Management, July 7, 2009

As the economic downturn shows signs of being more than a cyclical blip and the current cost of construction approaches $500 per square foot or more in some markets, hospital executives are interested in learning how to cut down on excess space and work more efficiently. Consequently, reports of Virginia Mason Medical Center, Seattle, and other facilities reducing space utilization by 20 percent to 40 percent with lean management strategies have caught the attention of senior executives and facilities planners.

The term “lean” refers to a philosophy and management system that creates value by eliminating inefficiencies and is often associated with Japanese manufacturing, particularly the Toyota production system. However, many of its principles came from American supermarket stocking practices. And, while the lean philosophy and systems are most commonly used for operational and systems planning, many of the tools and concepts can be incorporated into the facility planning and design process to prevent excessive, underutilized and poorly designed space.

Lean applications in visioning

Visioning is traditionally the first step in the planning and design process in which the design challenge is defined and the project vision and goals are established. Several lean tools and processes can be integrated into visioning, including the following:

Lean planning was used to maximize patient flow in the front desk area of the Melinda French Gates Ambulatory Care Building at Children’s Hospital Regional Medical Center in Seattle.

Assemble a lean team. Historically, the health facility planning process has been led by department-based user groups that some feel rarely challenge current systems and often result in replicating the status quo—only on a larger scale. The lean process team is a small, cross-functional and diverse group that is charged with removing inefficiencies from the processes and planning the optimal space. It is important that the group is led by a team leader who is responsible for achieving the operational goals and will champion ongoing change management when the new department is opened.

Clean up the workplace. Before implementing any change or planning for a new facility, the lean approach starts with cleaning up the existing workplace using a “5S” tool that can be translated as:

• Sort. Keep only what is needed.
• Straighten. Properly organize the materials that remain.
• Shine. Show pride by thoroughly cleaning the workplace.
• Standardize. Define a specific location for equipment and supplies.
• Sustain. Develop a plan for maintaining a clean, organized workplace.

Although this task may seem cumbersome or tedious to complete before beginning facility planning, being thoughtful about the 5Ss is an effective way to ensure that space is not planned for unnecessary equipment or supplies.

BEFORE AND AFTER: A floor plan for the pharmacy area at Children's Hospital Regional Medical Center in Seattle before and after lean design tools were applied to improve traffic flow.

Gemba (“Go see”). In the lean philosophy, the first step in solving a problem is gemba, or go see where the work happens. For facility planning, this is equivalent to rigorous documentation of the current situation. This should include the traditional operational and facility planning metrics: square footage, number of major treatment rooms, staffing patterns, treatment/turnaround times and specific use of each room as well as direct observation of activities that occur in the space.

Let the customer define value. The customer defines value in the lean philosophy. During lean planning, health care stakeholders are invited to tell the planning team what is important to them. At one recent event, an open-heart surgery patient identified the most important thing for him was the shift change. He described his daily anxiety related to not seeing anyone for two hours at the shift change, not knowing who the next nurse would be and not knowing if the right information was communicated. His definition of value contributed to the report process being shifted to the patient bedside in the redesign of the unit.

Lean planning applications

Abbreviated versions of lean process improvement tools also can be integrated during the functional and operational programming phase, in which the operating systems are identified. These tools and processes include the following:

Kaizen site visits. Many projects start off with site visits to other facilities to identify best practices. A Kaizen (meaning “continuous improvement”) site visit focuses not only on best practices but also on problems that can be eliminated in the next project.

For example, one hospital planning group visited a new, efficiently designed emergency department but felt the waiting room still had a bus station feel. Therefore, the renovation project replicated many of the best practices they observed but also sought to improve the waiting room situation through a series of smaller subdivided waiting areas.

To create a spaghetti diagram, each step of a process is mapped out on a floor plan. The resulting diagram clearly illustrates areas where wasted motion and bottlenecks may occur.

Removing inefficiencies. This is at the heart of lean. In facility planning, it is most often thought of in terms of underutilized space. Lean expands this thinking to include inefficient time, such as waiting; inefficient inventory, such as oversupply; and inefficient motion, due to excessive walking or movement of patients or supplies. The following lean tools, in a somewhat abbreviated form, may be helpful in this phase of facility planning:

• Value stream mapping. This tool involves identifying each step of a process on a flow diagram, then classifying each step as value-added or nonvalue-added. Finally, efforts are made to remove nonvalue-added steps and streamline the process by grouping steps where feasible. For example, the registration, triage and nursing assessment processes of an emergency department may be combined in a single location with the repetition of basic information minimized.
• Spaghetti diagram. To create a spaghetti diagram, each step of the process is mapped on a floor plan of the area. The resulting diagram, which often resembles spaghetti, clearly illustrates wasted motion and areas where bottlenecks occur. Dense, congested lines around the nursing unit medication room may suggest the need to decentralize some of the functions.

Getting to the root cause of a problem (“Ask ‘why’ five times”). The focus of lean is to get to the root cause of a problem and solve it. This very simple technique, developed at Toyota, works well in a group setting and simply consists of asking “why” five times. There is nothing magical about the number five except that it is typically the number of times it takes to get to the root cause.

For example, in response to noise concerns at one health care facility, it was asked why the large, central nurses’ station existed. By the fifth “why,” it became clear that in the era of electronic information and patient-centered care, the centralized nurses’ station serves little purpose and can be replaced by carefully planned work areas, some of which are decentralized closer to the point of care.

Fix processes first, then space. Many recently designed emergency departments have similar or longer patient treatment times than the emergency departments they replaced. This is most likely because optimal processes were never implemented in the new, larger space. To avoid this situation, the lean approach is to fix the processes first—often through small, rapid experimentation—and then plan space.

For example, one hospital debating the value of a dedicated radiographic room in the emergency department designated a room in the adjacent radiology department as the emergency department room and tested the concept for three weeks. The hospital found a significant reduction in emergency department patient turnaround times and was able to document the additional staffing costs and impact on other radiology patients. Ultimately, the concept was maintained and successfully incorporated into the new emergency department.

Lean space programming

The lean philosophy and tools also may help planners look at the space programming phase, in which individual room and space requirements are identified in a new way. Some useful lean elements that can be used during this process include the following:

Honoring the worker. Planners who are interested in applying lean approaches may want to start the process by rethinking how space is used to respect and honor workers. In Western culture, the amount of space often signifies importance or a valued department. As a result, offices or treatment spaces are often oversized or even supersized. Conversely, in the lean culture, the work space respects and honors the worker not by its size but by providing a clean, safe, efficient work environment.

Standardized work leads to standardized space. One of the three foundations of lean is standardized work, based on the simple concept that the optimal way to perform work should be defined and adhered to as a way of ensuring quality. However, in hospital design, spaces often start out standardized and end up customized. A lean planner would not accept several different sizes and designs of a medication room but would ask “How can we standardize this space to support the optimal work patterns?”

Storage space. The most common request in programming health care facilities is more storage space. According to lean expert Kiyoshi Suzaki, “excess inventory is the root of all evil.” One lean technique is to provide a simple inventory management system, or kanban (Japanese for “signal”), that indicates when inventory is needed. Health care workers are known as hunters and gatherers. Due to complex, inefficient storage systems, workers need to search out supplies and tend to hoard them to make sure they are available when needed.

In the space programming process, planning storage space should be based on putting supplies where they are needed and implementing a simple, visual kanban system for restocking.

A lean design process

The design phase incorporates the previous phases and begins to develop a physical solution. Several lean tools may be considered in this phase, including the following ones:

Starting from scratch. An advanced lean method called 3P, for “production, preparation, process,” involves starting with a clean sheet of paper and designing the optimal processes. The following two components of this method are applicable to the design phase:

• Seven solutions. In the lean 3P method, each problem requires seven alternatives or solutions. Although seven may seem excessive, the concept is that the first few solutions are generally easy and the remaining ones will force the planners to stretch their thinking.
• Waste-free solution. Next, the seven solutions are evaluated not on whether everyone likes the design but instead are reviewed based on the ability of the scheme to minimize waste such as construction materials, labor, square footage, energy costs, time associated with patient or material transport or other criteria.

Real-time mock-ups. Many architectural processes involve a full-scale mock-up, usually in a warehouse or other large space on campus where users visit the mock-up and offer comments. While these mock-ups tend to be very helpful, one lean tool that can be even more helpful is the real-time mock-up.

In a recent project, for example, a nurse manager suggested that a better approach than an off-site intensive care unit room mock-up would be to build the proposed room at the end of the hall and let the nurses start to use it. This gave a more realistic evaluation of how the space would be used and nurses were able to start implementing processes and using the equipment planned for the new unit ahead of time.

Stopping the line. As part of the Toyota production system, every worker on the assembly line has access to a cord that he or she can pull to stop the line when they see a problem. This empowers employees to be proactive about quality issues. Facility planning team members also should have the ability to stop the line throughout the planning process.

It is important to identify problems prior to reaching the end of the design phase—before concerns get embedded in the construction documents and become expensive and time-consuming to fix.

Embracing lean successes