Lean-Led Hospital Design

Creating the Efficient Hospital of the Future

Naida Grunden, Charles Hagood

• Publisher: Productivity Press
• Year: 2012
• ISBN:
  9781466558359
• Edition: 1
• Topic: Business
• Subtopic: Operations
• Index: Business

Lean-Led Hospital Design explains how hospitals can be built to increase patient safety and reduce wait times while eliminating waste, lowering costs, and easing some of healthcare's most persistent problems. It supplies a simplified timeline of architectural planning from start to finish to guide readers through the various stages of the Lean design development philosophy, including Lean architectural design and Lean work design. It includes examples from several real healthcare facility design and construction projects, as well as interviews with hospital leaders and architects.

LEAN BACKGROUND AND MODEL

1

Chapter 1

The Two Faces of Lean: Process Design and Facility Design

There is no such thing as an architect or construction firm that can build you a Lean hospital. Lean is not a building. It comes from within.

—Kathryn Correia
Senior Vice President, ThedaCare

This chapter describes the difference between Lean process improvements and Lean hospital design. Although synergistic, they are different.

Introduction

The American healthcare landscape is changing again. As the nation faces increasing fiscal pressure, there is less tolerance for limitless financing of our healthcare system—the world’s most expensive,¹ which consumes over 17% of the gross domestic product (GDP)² while leaving one in six Americans uninsured.³ This same system, which routinely performs medical miracles, is also responsible for the deaths of about 90,000 people annually due to medical error⁴ and another 99,000 due to hospital-acquired infections.⁵ Other nations do far better with far less.

The case for improving quality and safety while reducing cost has never been clearer, and the stakes have never been higher. Although manufacturers have long known that improving quality reduces cost, that understanding has been slow to dawn in healthcare. There is growing acceptance that safety and cost reduction are all of a piece. Now the hard part begins—learning how to make dramatic quality improvement.

New Healthcare Policies May Force the Issue

The American healthcare system has some of the most advanced health remedies and technologies in the world, as well as competent and compassionate healthcare practitioners. But our combined technology, science, facilities, equipment, and compassion are only as good as our ability to deliver them. Delivering healthcare requires a completely integrated system that fosters respect for patients and workers, provides the best known care efficiently every time, and improves continuously. Such a system delivers value to each patient. We do not deliver care perfectly—yet.

New healthcare policies and reimbursement experiments at national and state levels are pushing healthcare toward a more integrated, collaborative model of care, in an effort to improve delivery and reduce cost. Tucked into the 2010 Patient Protection and Affordable Care Act is the attention-getting provision for voluntary participation in accountable care organizations (ACOs). In general, ACOs “create incentives for healthcare providers to work together to treat an individual patient across care settings—including doctor’s offices, hospitals, and long-term care facilities.”⁶ The idea is to reduce Medicare and Medicaid costs by paying for integrated, rather than fragmented, care.

Currently, Medicare and Medicaid pay for individual transactions—each doctor’s visit, x-ray, hospitalization, test, and so on. When it is paid for like piecework, the care itself becomes piecemeal, rather than one coherent event. Furthermore, paying for piecework encourages more pieces, meaning overuse and higher cost.

New emphasis will be on paying for “episodes of care.” That is, Medicare and Medicaid will provide a lump sum for the treatment of a person’s illness—from the initial diagnosis in a doctor’s office through flawless hospitalization and discharge, rehabilitation, and follow-up—all in an effort to avoid acute problems that result in hospitalization and readmission. Health systems providing the highest quality and most efficient care should find the reimbursement adequate (in other words, they will not lose money on Medicare payments⁷).

One clinician explained the shift in approach this way: We have been paying for, and receiving, a bag full of knurled wheels, pinions, levers, and screws, when what we really needed was a watch. In the new scheme, doctors and hospitals will be paid to provide watches. Their pay will be based on patient outcomes, with bonuses for reaching quality benchmarks, instead of being paid for the number of tests and procedures they conduct. They will also be subject to new transparency requirements, divulging the error and infection rates and other safety measures on which they will be ranked.

The idea behind the legislation is to encourage hospitals to compete on quality. To operate in this demanding new healthcare environment, the hospital itself must change, giving far more consideration to the patient’s experience and less to the individual power structures, often called silos, that have existed in hospital departments. Departmentalism, top-down management, command-and-control leadership, and the hospital hierarchy itself must now respond to the demand to collaborate across long-perceived boundaries. To meet the new demands for improved quality and safety and reduced cost, hospitals will have to provide consistently efficient and excellent care to every patient.

These demands will change how hospitals are run. They will also change how hospitals are built. Using Lean as (1) the operating system of the hospital and (2) the guiding philosophy behind facility design is the most enduring way to meet these new demands.

What Is Lean?

Lean is a management philosophy based on two tenets: continuous process improvement, and respect for people. It is a strategy backed by process improvement techniques that were introduced at the Toyota Motor Company shortly after World War II. Decimated by war, the Japanese firm knew that if it were to compete on the world stage, it would have to do much more with much less. Stockpiling inventory, for example, was out of the question. Using techniques promoted by the American quality expert, W. Edwards Deming, Toyota began a cycle of continuous improvement that continues today.⁸

In the 1990s, in Seattle, and in the early 2000s, in Pittsburgh, hospitals began experimenting with the tenets of the Toyota Production System (TPS) as a way to improve healthcare delivery systems by reducing waste and improving quality. They discovered that, in addition to measurably improved performance, impressive cost savings also resulted.

What is Lean? Simply stated, Lean is a structured way of continuously exposing and solving problems to eliminate waste in systems. The objective is to deliver value to patients (customers).⁹ The components are, in order:

1. People. Lean, first and foremost, values and respects people—patients as the recipients of services (customers), partners in care, and the reason for the hospital’s existence; frontline workers as precious resources and the source of limitless creativity; and leaders as the hands-on visionaries who move the organization toward the goal.

2. Process. Lean provides a commonsense, practical approach to transforming processes, which is rooted in the scientific method (the way things get done). The objective is the elimination of waste.

3. Design. Process transformation can be supported and accelerated through efficient design (of buildings, facilities, equipment, and technology).

To build a Lean hospital, Lean process improvement as a leadership strategy and frontline reality must precede Lean architectural design.

It is possible to begin Lean process transformation at the same time that an architecture project begins. In fact, Chapter 4 describes a Lean organizational system introduced in a brand-new hospital that was just hiring staff. But Lean-led architectural design proceeds farther and faster and produces better results when the hospital has already made significant progress with Lean process improvements—especially when everyone, including executive leadership, is active in those improvements.¹⁰

Leadership: The Key to the Kingdom

Hospital A decides to start a Lean transformation. Leaders engage engineers and consultants steeped in Lean knowledge from other industries to help spread this philosophy and management system, initially as a way to solve problems. The consultants work closely with the people in the quality department. They help train teams of frontline workers and mid...