Lean-Led Design is a systematic approach to healthcare architectural design that focuses on defining, developing and integrating safe, efficient, waste-free operational processes in order to create the most supportive, patient-focused physical environment possible. 

Steven Spear identified the Four Rules-in-Use that permeate processes in his 1999 book, “Decoding the DNA of the Toyota Production System.”  The four rules have since become known as the fundamental building blocks for defining and optimizing the complex, multifaceted process steps that are inherent in today’s Lean healthcare delivery system.  As more attention is given to healthcare architectural design to support Lean processes, the four rules are a logical platform for articulating the characteristics of a supportive Lean-Led Design Project.

The Lean Led Design Principles below align with Spear’s Four Rules to optimize the Healthcare Delivery System:

Rule 1: Activities

• Think system, not silos. Look for opportunities for sharing spaces between services, for example, prep and recovery rooms that serve all invasive procedures.  If possible, co-locate exam room spaces between two departments with opposing peak census needs, such as Pre-admission Testing and the Emergency Department.  This will result in increased capacity for both. 
• Standardization in design promotes defect-free, standard work. Standardize configurations to reduce variations in work processes and promote long-term flexibility.  In shared workspaces such as medication rooms, a standardized layout permits instant familiarity and reduces the potential for error.

Rule 2: Connections

• Create a visual workplace. Build in visual cues that permit the staff to instantly determine normal from abnormal in their workplace. Designate parking places for frequently used equipment to prevent time spent searching when it is in use. 
• Caution! Waiting is waste. Carefully scrutinize waiting rooms beyond the point of entry (public lobby and reception areas).  Don’t design sub-waiting areas to queue patients: rather than shift the wait from one area to the other, strive to move patients through the system with smooth, one-piece flow. 

Rule 3: Pathways

• Pathways should be direct. Make way-finding intuitive.  Make it easy to visualize the destination from the point of entry.  Remember that straight corridors make stretcher travel easy with minimal motion waste. 
• Design in smooth flow and motion. Design the layout for smooth flow, where work proceeds in one direction and the start and end are in proximity.  Consider how the work starts and ends and consider the hand-offs and travel in between.  For example, are the patient and family member arriving for imaging able to enter and exit the same door near their car? 
• Make the trip to the toilet a Lean journey.  Configure patient rooms with the toilet room on the same wall as the headwall to reduce travel, promote patient autonomy, and reduce the risk of injury to patients and staff through falls. 
• Space should be intentional.  Design for every square foot needed and no more.  The belief that space will solve problems is a myth:  excess space leads to increased travel distance (motion waste) and stockpiling of supplies and equipment (inventory waste).  Process redesign solves problems. 

Rule 4: Continuous Improvement

• Make the environment easy to change.  Consider using standardized modular equipment, casework and workstations on wheels to provide flexibility for continuous improvement.  Make storage accessible, flexible, visual and temporary.  Create long, shallow equipment rooms to keep items from being lost and prevent having to move items reach equipment behind. Designate visible parking spaces for each piece. 
• Think quality at every step. Design in inspection (quality checks) before the product/patient/service is passed on to the next level. Incorporate ways to visually communicate real-time progress toward continuous improvement goals.

Whether it’s a small department renovation or a large hospital replacement project, when Lean Healthcare processes and a supportive building work together the result is the same – higher quality at a lower cost. 

Interested in Lean Design? Check out www.leanledhospitaldesign.com for more information on Lean-Led Hospital Design: Creating the Efficient Hospital of the Future, the new book from Naida Grunden and Charles Hagood, available March 2012.

This week’s blog was written by Teresa Carpenter, RN, Director, Lean Clinical and Facility Design.

Teresa brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience as well as move-in expertise.

Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa serves as an educator, advisor, advocate, and interpreter for Lean healthcare integration into a wide range of clinical and hospital design, renovation, construction, and move-in projects.

Following more than 12 years in acute care, Teresa transitioned to clinical operations coordinator for an internationally recognized leader in healthcare architectural design. Among her project experience, she was the lead planner on the nationally recognized St. Joseph’s Hospital in West Bend, Wisconsin, the world’s first hospital designed to reduce medical error.

Teresa holds a B.S. in Business Administration from the College of Charleston, and a B.S. in Nursing from Trident College in Charleston, South Carolina.

As a Lean Clinical Design Consultant with 10 years experience working along side well meaning hospital employees in the planning and design of numerous building projects, I have come to recognize the signs and symptoms of a very insidious infirmity. I have termed it Post Traumatic Space Deprivation Disorder or PTSD(D). It can dramatically distort reality, lead to improper allocation of square footage and interfere with project goals such as improving the quality of care and operational efficiency.

Just as is the case of the mainstream mental health affliction, post traumatic stress disorder, hospital caregivers have endured great difficulty, frustration, and even helplessness in performing their daily responsibilities. They have battled the inefficiencies of aging, antiquated environments with semi-private patient rooms, cluttered workspaces, and distant, small supply closets. When called upon to participate in the design of a new work environment, excitement can quickly turn into anxiety. Making decisions about process and space can be overwhelming even for lean thinkers.

Even under the most ideal circumstance, as when an organization is one to two years into their lean transformation, the typical design process focuses on floor plan development by individual departments which can create work process barriers for today’s extremely multidisciplinary treatment model. Left unchecked, PTSD can negatively influence attempts to reduce waste in the new environment and even contribute to the most dastardly budget buster; scope creep.
The symptoms associated with PTSD are remarkably similar to those of its medical counterpart. Early recognition and aggressive treatment is essential in overcoming the negative effects of PTSD.

Symptoms of Post Traumatic Space Deprivation:

• Flashbacks – Valiant attempts to recreate a perceived happier time in the past (like medical school or a previous work situation)
• Bad Dreams – Exaggerated memories of the rare or occasional occurrences when limited space or capacity caused delays in patient care delivery. (“Feeling like you must build the church to accommodate the crowd on Easter Sunday”)
• Frightening Thoughts – An uncontrollable fear of not having enough storage space, windows and bathrooms.
• Rationalizing – Creating endless logical reasons for maintaining sub-optimal or dysfunctional current state processes. (Holding on to “the way we do it now”)

Steps to Overcoming Post Traumatic Space Deprivation:

1. Get on the Lean Path and Stick to it! – It is never too late to begin transforming culture and process using lean thinking. One word of caution – Lean design is a little like purchasing a size 6 wedding gown on clearance in January and vowing to lose 50 pounds before your June wedding. There are no refunds on new construction if you have “fallen off the lean wagon”!
2. Value Stream Map Current State Processes – Value stream map current state processes and pay special attention to understanding how the environment may have shaped process. Identifying existing building barriers will prevent them from being transferred in the new environment.
3. Perform Direct Observations – There is no substitute for going to the Gemba or where the work is done. It is rare that the reality of direct observation matches how the process is perceived to be working.
4. Utilize 3P (Production Preparation Process) – Develop ideal future state processes by focusing on waste elimination in process design. Lean processes can then accurately inform the architectural design.
5. 5S the Current State Environment – The exercise will not only give design participants a more accurate picture of how much space is really necessary to accommodate supplies and equipment in the future state, it will improve efficiency and staff satisfaction with the existing work environment.

PTSD can be overcome through diligent application of basic lean principles. Design team participants can redirect their natural human tendencies toward more value added design solutions that focus on healthcare’s most important customer – the patient.