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.
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.
Properly organize the materials that remain.
- Shine. Show
pride by thoroughly cleaning the workplace.
Define a specific location for equipment and supplies.
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
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.
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
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
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
- 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
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
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.
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?”
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
A lean design
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
- 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
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
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.
Health care organizations
embracing the lean philosophy have already shown dramatic
reductions in the use of resources and an improvement in
quality. Therefore, it makes sense that these lean concepts and
tools be carried over into the facility planning process as