By February 10, 2010 11 Comments Read More →

An Article about Lean Design and Construction for Hospitals

In this article, “Go Lean in 2010: Reducing Waste in Construction,” there’s a nice description of the design process that Seattle Children’s Hospital uses to get staffed engaged in making sure new space is designed and built to support their processes and patient needs.

From the article:

[Seattle Children’s] gathered the major stakeholders in the project, including medical and management staff, the architectural firm, the contractors, and the construction manager, and discussed how they could not only take the project Lean and fast-track it.

This is a great example of the hospital (as client and process owner) not letting the architect dictate the layout.

I’ve seen many  a few organizations, as they are learning about Lean and using the principles to redesign space, get into conflicts with architects who, sometimes, don’t listen. In one case, the architect completely disregarded the hospital’s re-design of the laboratory to give them something that was like the laboratories they always built at a typical hospital. That was exactly the problem to begin with! The architect brought a typical silo-ed layout with separate mini-departments within the department, even AFTER being given guidance by the lab that their new cellular cross-functional layout was the way to go.

Lean thinking and lean processes drive different layouts than a typical hospital. Thankfully, that other hospital’s leadership pushed back and educated the architects about why their Lean design was better and why that was the only path forward.

Seattle Children’s has a very proactive process for managing Lean design. I saw this first-hand when I visited last August, seeing staff members engaged in what’s often called a “3P” process – for Production Process Preparation.

I saw many elements of what’s described in the article:

Rather than have the team continually review and alter the architects’ paper design plans, which often takes facilities months, they decided to take the design to scale and finish the process in two weeks. The architect and contractors measured out and built a version of a patient room and sections of the floor to scale. The medical and administrative teams then toured the mock-up and tried out the design. Design flaws could be swiftly spotted and modified on the fly allowing the hospital’s team to test out suggestions and changes.

Being able to see and touch the space helped everyone see where the inefficiencies in the layout were from the location of the patient bed to where the equipment should be positioned. They went so far as to analyze storage space, determining the exact size of the supply closet based on the historical supply data—thereby eliminating the need for large supply closets with unused space that was badly needed for exam rooms. The team mapped the flow of patients, supplies, and providers and even counted the actual number of physical steps it would take for different processes to be completed, such as a nurse gathering needed supplies.

I’ve heard of other hospitals building cardboard mockups of new spaces out in the parking garage so staff members can walk through it and make PDCA revisions before it’s built. That’s the time to make changes, when the changes are easier and less costly. I saw where Seattle Children’s used foam board mockups (small ones) before they got to the full-size mockup phase.

My advice to hospitals?

  • Design your process BEFORE you design your space
  • Analyze the existing process and layout to understand the waste and problems, so you can incorporate those lessons into new space
  • Take control of your design process – don’t abdicate responsibility to the architects. Work with them, but realize it’s YOUR space that you have to live with for years after construction

What have you or your organization done to incorporate Lean methods or learnings into new construction or the redesign of existing space?


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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11 Comments on "An Article about Lean Design and Construction for Hospitals"

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  1. Stacy says:

    While I think there are more quality architects than you imply, I nevertheless agree with your overall point. First, hospitals need to take control of their future by planning processes before designing spaces. Design does indeed impact how people work. Second, architects need to understand the processes of the hospital before designing. This is often a disconnect. It has been done well and not-so-well, but healthcare processes–not just cookie-cutter space issues–need to become part of every hospital architect’s lexicon. Is it lean? Maybe. It’s really just smart, responsible design. If hospitals go through process improvements before designing a new facility, and then architects disregard that information, this is clearly a failure on both sides. Hospitals can’t be victims of the ignorance of designers; they need to be part of the team. Having said that, maybe architects who design collaboratively, intelligently, and respectfully need better marketing departments…they do exist.

  2. Mark Graban
    Twitter:
    says:

    Stacy – thanks for your comment. I didn’t mean to smear all architects, but I have seen troubles with a few of them.

  3. Jefferson Martin
    Twitter:
    says:

    Someone needs to offer CHOP some help here in Philadelphia.

    Consider a children’s hospital which places new PC workstations to capture patient information digitally into each of their examination rooms and designs the ‘cart’, for lack of a better word, with it’s 10baseT ethernet wiring and router, complete with blinking lights and other interesting paraphernalia six inches above the floor level.

    My two year old’s examination devolved into one of a snarky doctor chastising us for not being able to keep our child from touching all the interesting, blinking stuff placed directly into my child’s visual field.

    My complaints about inappropriate design of the cart setup met with only an indignant about the importance of the digital information gathering process which, to me, has replaced doctor patient interaction and ended in a stalemate between a doctor and an engineer.

    This may not be an example of an architectural issue, but it surely qualifies as an example of a design issue which cost CHOP a customer.
    .-= Jefferson Martin ´s last blog ..Middletown Ignition Source =-.

  4. Mark Welch says:

    We’ve had four 2P (process preparation – redesign of existing areas, not new construction) events in my hospital since I arrived in 2006. We deliberately left the architects out or at most involved them minimally. Here’s the question we asked ourselves… “What do you think a guy who is paid by the square foot is going to recommend?” On the other hand, we have brought one in for just small sections of our design phase and he was very reasonable, open-minded, and truly wanted to understand Lean concepts as they applied to the designs. We had a construction manager from the same firm as the architect participate fully with three of the four 2Ps. He had a detailed knowledge of the construction our hospital and was very receptive to lean and out of the box thinker – a solid asset to the team. He truly saw us as a customer and helped us reduce motion and total square footage using lean concepts. So, I think it comes down to the particular individuals, but you’ve always got to be on the alert for the conflict of interest.

    We’ve also involved our infection control specialist in each case so that her expertise could play a role. Using the best infection control practices for design and construction were of great value.

  5. Mark Graban
    Twitter:
    says:

    And to be more fair, there ARE many architects and construction firms that are learning about Lean. I think we just have to be careful it isn’t a buzzword.

    For example, there is the Lean Construction Institute:

    http://www.leanconstruction.org/

  6. Andrew Bishop
    Twitter:
    says:

    We are building a new production laboratory (not medical, but plant tissue culture) under sort of forced march conditions in Bogota due to loss of a lease. Unfortunately the lab has not yet been a major focus of our lean transformation in Colombia, so we are not fully prepared with new thinking and processes and the local leadership is not trained in lean process design. We haven’t really studied the current state, let alone envisioned an ideal state or near term future state.

    So what do we do, knowing what we know about lean but required as we are to commit resources to new construction on a short schedule?

    Two things: We took a high level view of material flows to assure that pathways were as simple and direct as possible at a site-wide level, since we can see this even without detailed process or value stream mapping. And, more important possibly, we made sure that NOTHING in the space except the bearing walls (four exterior) would be fixed or expensive to move in the future if process or value stream change called for it. A fairly primitive level of design, but our experience with lean deployment at other sites has been that facilities layouts will be required to change. My goal was to accommodate future changes of layout at minimum expense as we transform processes and value streams in the new lab.

    Probably not completely applicable in practice in a hospital setting but some principles to keep in mind, nonetheless.

  7. Jefferson Martin/synfluent
    Twitter:
    says:

    Andrew Bishop: Interesting comments on creating flex space under the premise of future re-purposing.

    An equally interesting architect that I am sure you are familiar with would be Albert Kahn, whose open floor plan buildings for Henry Ford are almost mythologized.

    Kahn had some help, though, when Tesla’s portable AC electric motor replaced overhead driveshafts and belt takeoffs for machinery in those settings.
    .-= Jefferson Martin/synfluent ´s last blog ..Middletown Ignition Source =-.

  8. Mark Graban
    Twitter:
    says:

    Andrew – I think that approach would apply. Designing for flexibility is a great design concept when you can pull it off. Using a lab example again, the old-school approach had either separate rooms (which created silos and interrupted flow) or it had the classic black-topped permanent benches that couldn’t be adjusted.

    Modern lab design is a big open space with a utility grid in the ceiling for flexibility about where you plug in stuff (for power and networking). Tables on wheels, everything being modular, those are great design principles for kaizen or growth.

  9. andrew says:

    We are currently designing a new surgical centre.

    Having visited in excess of 100 hospitals across the UK, europe and the US, both public and private, my experience is that the variability in the quality of architects is enormous and that many fail the most fundamental tests when it comes to optimising design.

    There are so many classic hospital design failures; nice building but no dirty theatre corridor, nice design of a childrens wing, but the entire thing is made of glass and in the summer with no air conditioning and no windows that open you can have baked toddler (that one won an award), sterile services located more than a mile away from their highest user and 4 floors difference.

    We’re currently designing a new surgical centre, comprising outpatients, theatres, procedure rooms and beds / wards.

    The architect was given a brief by someone other than us 4 months ago.

    We came in, told him it would not work, spent 3 months working with surgeons, nurses, wards and clinics on how it should work, re-drafted a brief, provided a schedule of accommodation, made the architect present revised drawings along with an explanation of why some things could be incorporated and others could not (space constraints, it was limited by square footage and some infrastructure constraints).

    Some of the guidelines included but were not limited to:

    The building would be designed around the future processes, not the current ones on the basis if we did the latter we might as well simply paint the walls

    Every room must be identical in layout, none of this left handed backing on to right handed layouts you see in hotels to save on plumbing

    All rooms can be flexed for procedures

    The ratio of waiting area to clinic rooms needs to be appropriate, not 35% of the square footage given over to 140 waiting seats for 8 clinic rooms just so they could have a nice entrance. Clearly an architect that had not heard of form following function.

    And so on and so forth……..the briefing with comments from all staff extended to thousands of words, meetings, briefings and workshops to come up with the future state…….

  10. Steve says:

    Yes, If delivered correctly it can save companies a lot of time and money. Its just educating companies how it can work and beneifit them / users and employers in the long term. Good resources can also be found on en.wikipedia.org/wiki/Lean_construction.

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