Planning and Designing Healthcare Facilities

A Lean, Innovative, and Evidence-Based Approach

Vijai Kumar Singh, Paul Lillrank, Vijai Kumar Singh, Paul Lillrank

• Publisher: Productivity Press
• Year: 2017
• ISBN:
  9781315393483
• Edition: 1
• Topic: Negocios y empresa
• Subtopic: Operaciones

The planning and design of healthcare facilities has evolved over the previous decades from "function follows design" to "design follows function." Facilities stressed the functions of healthcare providers but patient experience was not fully considered. The design process has now crucially evolved, and currently, the impression a hospital conveys to its patients and community is the primary concern. The facilities must be welcoming, comfortable, and exude a commitment to patient well-being. Rapid changes and burgeoning technologies are now major considerations in facility design. Without flexibility, hospitals face quicker obsolescence if designs are not forward-thinking.

Planning and Designing Healthcare Facilities: A Lean, Innovative, and Evidence-Based Approach explores recent developments in hospital design. Medical facilities have been adapted to the requirements of clinical functions. Recently, the needs of patients and clinical pathways have been recognized. With the patient at the center of the process, the flow of tasks becomes the guiding principle as hospital design must employ evidence-based thinking, and process management methods such as Lean become central.

The authors explain new concepts to reduce healthcare delivery cost, but keep quality the primary consideration. Concepts such as sustainability (i.e., Green Hospitals) and the use of new tools and technologies, such as information and communication technology (ICT), Lean, and evidence-based planning and innovations are fully explained.

1

Introduction

V.K. Singh and Paul Lillrank

During the past few centuries, healthcare has slowly emerged as a science-driven profession. Still, only about one-third of what doctors do is based on scientifically justified evidence. Nevertheless, there is a consensus that therapies should ideally be based on theories. No respected professional would apply the reasoning of prescientific medicine, where doctors claimed that if their patient was cured, it was proof of the efficacy of techniques, while if their patient died, it simply showed that the disease was incurable.

In his book, Bad Medicine, Professor David Wootton¹ makes the case that Western medicine from Hippocrates to the late nineteenth century did more harm than good. The turning point came in 1865, when Joseph Lister performed the first surgical intervention involving antiseptics. Soon, the idea of aseptic surgery followed, meaning that instead of the surgeon cleaning the scalpel on his coat between patients, instruments were sterilized through boiling. In effect, modern medicine could seriously claim its capacity to save lives only after 1942 when antibiotics were introduced.

As elsewhere, medicine science progressed through adapting the basic principles of methodology. For Hippocrates, every patient and their problem were unique. With such a mind-set, no meaningful categorizations of states, cures, and effects could be collected. Only after symptoms, conditions, diseases, interventions, and outcomes were classified— following the principles of Linnaeus’ ordering of the biosphere and the periodic tables in chemistry— could meaningful data be collected. With data on hand, it became possible to compare and set up experiments to collect evidence. Classify, count, and compare.

In many areas of health and welfare, the progress of the scientific method is still painstakingly slow. This applies also to the topic of this book, the facilities and the production sites where health services are performed. Before theory-based therapy and evidential effectiveness, hospitals were warehouses for the sick, sanctuaries where the placebo effect could do its job, or the last place to rest for those who could not afford a bed of their own.

It is obvious that the location and circumstances where a therapy is provided play a role in determining the outcome. A person in a weakened state needs shelter, anybody with an open wound benefits from a germ-free environment. Indeed, the idea of the healing environment, though ancient is still valid. As the medical profession’s skills improve and specialization occurs, and when more devices, supplies, and pharmaceuticals are needed, the hospital obeys the same logic of location, concentration, and organization as any production facility. As patient volumes and capital intensity grow, economies of scale and scope come into play. The logic of production and economic forces, form and function, location and access, cost and space, closure and control, efficiency and comfort, advanced toward a dominant design: the general hospital as a multifunctional health factory.

However, advances in technologies, such as information, computing, logistics, clinical methods, diagnostics, and devices, challenge the standard concept and allow for new ideas. Increasing wealth and housing standards erode the hospital’s monopoly on healing environments. With cheap and portable devices together with smartphones and wearable sensors as hubs of information gathering, aggregation, and analysis, the imperative of the centralization and concentration of facility-based services gives way to ambulatory field– based services. The hospital can be disaggregated to the “ hot floor” where invasive therapies are carried out; the “ hotel” where patients recover under observation; the out patient department to which patients commute for therapies; the emergency department with rapid reaction stand by assets; as well as assisted housing and social care. All can in various ways be nested within an urban landscape. A plethora of different arrangements can be imagined to follow the discontinuation of the hospital as the primary production site. Some caution, however, is required.

While progress in some technologies, particularly electronics and communication, has been breathtaking, it is good to keep in mind that not all technologies follow Moore’s law in doubling performance every three years. Batteries are a crucial element of the mobile Internet, yet the progress of battery technology has, as measured by the weight– power ratio, proceeded at a turtle’s pace of 4% per year. It will take 35  years for performance to double. When technology meets human behavior, anything can happen.

While it is exciting to play with visions of what might come, it is prudent to focus on what is possible. The history of medicine shows that something becoming possible does not yet guarantee it being implemented. It took two centuries from Leuwenhoek’s discovery of bacteria to the formulation of the germ theory of diseases. To the modern mind, the 50  years between the invention of anesthesia and its application in surgery seems incomprehensible. Powerful incumbents have resisted every disruptive innovation. Professionals tend to identify with their current competencies and resist radical change. While Wootton demonstrates the harm of Hippocratic prescientific medicine, he strongly emphasizes that this is not a case of malice, evil, or ignorance. Most of the doctors were sincere and dedicated, but while doing their best they did not know what they were doing. They just lacked evidence-based methods.

The evidence-based approach to hospital design seeks to break with a number of traditional lines of thinking and practice. Some of these are the assumptions that a hospital is first and foremost a building where patients come to stay in bed and patiently receive scheduled therapies and undergo monitoring. Buildings can be described with floor space and room requirements. Planning can be a top-down process based on intuition and authority that pays little attention to how patient processes, staff movements, and logistic flows actually happen. Patients and staff representatives may be asked for their opinion, based on the superficial assumption that anybody can, in his or her head, translate 2-D drawings into a dynamic view of what will actually happen. There is the benevolence trap, the assumption that everything that is done with good intentions automatically creates value and nothing can be wasteful.

The general hospital is still a valid concept and is not going to disappear anytime soon, particularly in parts of the world where public health is poor, resources are scarce, and a majority of people are underserved. While visions are always welcome, the task at hand, and the theme of this book, is to improve on the dominant design, the standard general hospital.

The notions that facilities are important and that the scientific method is supreme lead straightforwardly to the call for evidence-based hospital planning. A number of design and planning principles have emerged and several of them are described in the following chapters.

REFERENCE

1.Wootton, David: Bad Medicine: Doctors Doing Harm since Hippocrates . Oxford University Press, Oxford, 2007.

2

Innovative, Lean, and Evidence-Based Design

V.K. Singh

CONTENTS

Introduction

Lean and Innovation

Evidenced-Based Design (EBD)

Lean and EBD

Innovation, Lean, and EBD

Summary

References

INTRODUCTION

Healthcare affordability is a major concern in poor and emerging ­countries, while rich and developed nations continue to spend and demand more, as in the United States where annual healthcare spending per capita was $8602 (17.2% of gross domestic product [GDP]) in 2011, yet people are still not happy. Cost containment is possible using an evidence-based system and quality tools such as Lean, and judiciously using technology and innovation. The aim is to deliver healthcare at optimum cost keeping quality in mind. The concept of affordability needs to be further considered as what is affordable for one person may not be so for another person. Healthcare delivery comes at a cost that can be optimized, but the cost needs to be considered from the planning and design stage of a hospital as the operational costs of healthcare delivery are dependent on how well a hospital has been planned and designed. The planning team should have expertise in innovation, Lean, and EBD, as knowledge of these new concepts is considered essential. There are various cost centers in healthcare delivery such as pharmaceuticals, devices, diagnostic, and processes, which need to be controlled by these methods. Information technology (IT) has a big role to play and its use in planning, designing, and operations is vital. This chapter discusses these concepts and how they can be integrated to reduce costs.

LEAN AND INNOVATION

Lean and innovation are two sides of the same coin and complement each other. Lean means creating more value for customers with fewer resources. The Lean approach, a concept developed by Toyota, has been adopted by healthcare over the last few years. The goal is to provide value to the customer by continuously improving processes that have zero waste. It is estimated that there is approximately 90% waste in various manufacturing processes; however, it is not possible to remove all waste in healthcare because, unlike cars, patients and healthcare providers are not robots and patients are bound to ask for things that typically would be waste but cannot be eliminated. I define this as essential waste. It is estimated that 60%–65% of healthcare waste can be removed. There are eight types of waste: transportation (unnecessary movement of patients and materials); inventory (equipment and medicines stored over long periods), just-in-time inventory; motion (unnecessary movement of people, searching for investigation results, etc.); waiting everywhere in a hospital be it registration, diagnostics, pharmacy, operations, and so on; people not listened to and their talent not exploited; overprocessing (unnecessary ordering of tests that are not required); overproduction (preparing drugs that are not required); and defects such as medication errors, wrong operations, and so on. Efforts should be made to remove waste to add value to the customer experience and transform healthcare. Lean thinking aims to improve quality, reduce the cost of healthcare delivery, and increase profitability and the morale of providers. Listen to the voice of the customer—the patients and their families. The facilities are not for the providers but for the customer, which implies that the customer’s requirements should be integrated at the planning stage. Learn from your current circumstances and bring in a fresh pair of eyes. Go to the place where the work is being done, and list any changes suggested by staff. The staff then become owners of such changes in processes. Some minor changes can make a big impact on day-to-day work schedules. Do a comprehensive review of the organization’s workflow and downstream effects and create mock-ups and prototypes. Plan development and operations concurrently with design and construction. Listen to the views of staff and plan equipment from the drawing board stage to the design stage. The guiding principle of Lean is standardization. Synchronize the approach of the technology and construction implementation schedule.

Lean has linkages with the Donabedian model, a conceptual model that provides a framework for examining health services and evaluating the quality of healthcare.¹ According to the model, information about quality of care can be drawn from three categories: “structure,” “process,” and “outcomes.”² Struct...