The Skinny on Lean

Forget all that stuff about firmness commodity and delight.  Today’s design drivers are Lean, Green and Clean.  If you embrace evidence-based design, you probably already find your efforts fall into these categories.  Most institutions have fairly robust initiatives related to sustainability and infection control.  It’s the third leg of the stool where things get a little fuzzy.  While every vendor can tell you how their product contributes to your sustainability and infection control efforts, can they tell you how it provides greater value by promoting efficiency and service?  Lean is a concept that most embrace in principle but have no real idea how to put into practice-ask ten people to define Lean for you, and you get ten different answers.  Yet this is such a powerful tool for improving patient satisfaction, outcomes, employee retention, reducing errors and eliminating waste that any design effort that doesn’t take Lean into account is falling short of its potential.

Lean started at Toyota as a manufacturing process.  Apply it to the design of buildings unfiltered and a lot gets lost in translation, for example focusing on efficiency to the detriment of the human experience. The Lean Construction Institute, a non profit organization, is a great resource for helping architects and their clients work together to get a building design that supports its optimal use and generates value. I like to draw analogies to the Leaning Tower of Pisa as a mnemonic device in understanding why we need Lean:  inadequate foundations set in unstable soils and a flawed design led to a failed effort that corrective actions over it’s 177 year construction history (talk about inefficiency and waste) never did manage to put right. Lean processes help us take a step back and consider what we are really doing instead of getting swept up into the chaos of a frantic deadline:

A process about a process
A hospital can hire a Lean consultant and optimize processes without moving a wall.  As architects, our goal is to understand how design can support and even facilitate those processes. If the organization has not already done so, consider hiring a Lean consultant to observe existing conditions and help make improvements.  This allows your design efforts to be focused around the best operating conditions, not a bunch of old habits.  If a consultant isn't something the project can afford, do take the time to work with staff and understand and map the variety of activities they engage in daily to provide patient care.  You can do observations and start to notice the redundancies and waste that is built into the current system. 

Think differently about a solution 
Lean is also about empowerment.  By involving project stakeholders and coaching them through a collaborative process, you encourage them to think about how they could do their jobs better.  You also encourage everyone from the C-Suite on down to filter everything they do through the lens of whether it improves the experience of the patient.  This will inform the design in amazing ways and help you to set project goals that keep the design on track, even during value engineering.

The value proposition
Lean is, above all, a  multidimensional tool for improving value.  Value is a slippery metric.  It is not, as I’ve stressed multiple times in this blog, another word for cost.  Value may include cost, as when the lifecycle of a piece of equipment is measured against first cost and cost savings.  Value can also include intangibles, like improved satisfaction, that may generate revenue.  Still other measurements take into account indirect costs such as reduction in FTE’s or patient length of stay or lawsuits/non-reimbursement due to errors.  

Frank Zilm, Jody Crane and Kevin Roche have produced what I view as the most concise and understandable breakdown of Lean for Healthcare in their article for the Journal of Ambulatory Care Management “New Directions in Emergency Service Operations and Planning”   In their article they cite five key components:

Creating Patient Value
A value stream is a patient’s path through a set of services during a visit.  A facility will need to define value streams for all of the typical services they offer by department as well as by acuity level.  Departments then work collaboratively with leaders to identify ways to provide more value (such as shorter wait times, more amenities for family members, ease of access to the facility) or eliminate things that take value away (such as long waits for the transport team, inability to sleep well due to noise and interruptions) for each value stream they identify within their department.
Eliminating Waste
The next step is to categorize each element in a value stream as either value-added or non-value added.  The article suggests that non-value added items are one of eight forms of waste traditionally defined by Lean:

1.  Transportation – care delivery is delayed by the transport of patients, supplies or equipment
2.   Movement- staff should have supplies close at hand to their work areas, which should be proximal to the tasks/staff/patients they need to interface with. Think: right amount, right place, right time.
3.  Inventory- overstocked inventories represent capital that will potentially be wasted
4.  Waiting- this is wasted time for all involved.  In healthcare, this means less silos and territories and better utilization of resources such as exam rooms or OR’s.
5.  Overprocessing- doing more than the patient needs because of overlapping protocols
6.  Overproduction- generation of reports or materials that are not used
7.  Defects- errors or incomplete work that must be subsequently re-done.  Often there is waste generated by a lack of communication or even problems with wayfinding.
8.  Lack of human creativity- the ability to problem solve and improve processes

Promoting Flow
Study of service responsiveness within a system.  This uses tools such as queing theory to map flows from arrival through service delivery and exit, with a focus on responsiveness and system capacity.  Other ways to study flow include “spaghetti diagrams”  which track the movement of individuals through a system to identify where flow is impeded or non-linear (too much retracing of steps involved in a process).
Continuous Improvement
This is a quest for perfection that is embedded at every level of an organization.  By clearly identifying what will add value to the patient experience, staff at every level is empowered with the tools to suggest ways to improve performance. 
Developing People
Unlike traditional top-down leadership hierarchies, lean encourages a bottom-up organization that recognizes that those doing a job have the most insight into the processes involved.  By empowering staff at all levels, a more collaborative work environment is formed with a focus on delivering value over beauracracy. Resources for improvement are provided while obstacles are removed.

By working collaboratively and filtering it through the value process, it is easy to determine which strategies will make people better and which won’t.  These strategies can be reinforced through architectural elements. Focus on the value adds and drop the waste, and you’ll end up with a project a lot more successful than that famous belltower in Pisa.