In most health care systems, we introduce Lean into a system that already exists. In the case of hospitals, this means that you have to work within the constraints of an existing building. This usually introduces limitations – you cannot move operating theatres, or linear accelerators, for example. This is not a deal-breaker: Lean is built around continuous improvement, so incremental improvement to the quality of a service is a natural step. You don’t need to re-build a hospital before staff can start to improve a service. Several days in to an improvement event, however, it is common to hear people considering wistfully what would be possible if only area x could be moved to location y, or entire corridors could be moved to help improve flow for patients. After a few moments, staff usually shrug their shoulders and get back to the art of the possible.
‘Lean-Led Hospital Design’, by Naida Grunden and Charles Hagood, gives a glimpse of what can be done if a service does have the opportunity to design a hospital from scratch, using Lean principles, and focusing on what adds value for patients.
The book provides case examples of hospitals that had to re-build, and used Lean in the heart of the design process; hospitals that applied Lean after the build but before they moved in; the use of Lean in building an extension to a hospital, and in one rare case, an example of entirely new hospital that was not replacing a previous building, and could therefore be designed from the ground up, without having to worry about existing ways of working.
By and large, these seem to have gone very well, according to the account by Grunden and Hagood. There are some results that arise in several of the accounts, probably in an example of form following function. Concentrating on flow, separating patient areas from staff flow areas, and using flex areas seem common. Creating areas that allow flex of room use makes intuitive sense, given that many hospital areas are empty at night. Building A&E beds, usually busy at weekends and evenings, beside pre-operative assessment suites, which are normally busy during the day but quiet at weekends and evenings, and so allowing additional capacity without additional cost, for example, came up in several examples.
As Mark Graban points out in an essay within the book, Lean is based on continuous improvement and respect for people. In these examples, the voices of patients and family were prominent, and staff had a key role in guiding layout, working hand in hand with architects and engineers. This whole approach, of identifying value, understanding the voice of the service user, and supporting staff to influence development, feels like an improvement event writ large.
The scale of some of the projects were astonishing. Seattle Children’s, a famous name in health care Lean work, rented 60,000 square feet of warehouse space to build a mock-up of their new facility, to allow them to get the design right while it was still possible to change it. This followed on from an earlier project where they had built a mock-up of an entire floor of a new centre in a parking garage. They then walked patients, families and staff through the space, and simulated activities, again working out how to improve the flow before a builder poured a foundation.
Was this extraordinary effort worthwhile? Seattle Children’s thought so, or the organisation would not have done it twice, and on an increasing scale. According to Grunden and Hagood, in their first attempt, the hospital built after the staff and patients had the chance to use the mock-up was 25,000 square feet smaller than the original estimate of 110,000 square feet, and $40 million below the original estimate of $100 million, partly because of the marked reduction in changes to plans. Having worked on two hospital build programmes in the past, the idea that a building project can come in 40% under budget while maintaining quality – and even improving it – is astonishing. In the second case, the hospital ended up 50% smaller than originally estimated when staff had the chance to work on how space would actually be used, rather than using off the shelf assumptions.
There are numerous other examples that are interesting: several hospitals looked at the same information, and put their toilets on the headwall side of the patient room, so that there could be a hand rail the whole way, and patients did not need to cross a floor to get to the toilet. Supply management solutions often seemed similar, although not identical. Nurses in different cities came up with related solutions to related problems, particularly around room standardisation. Listening to the voice of the patient produced design changes, including changes reflecting local culture.
Reading this book did not give me the ability to design a hospital using Lean methods, but it certainly let me understand why I would want to use this approach. If you are designing a new hospital, or refurbishing an existing building, it is well worth reading. For people leading hospital Lean projects of any type, it would also reward an evening or two of browsing, as there are some good ideas that would be applicable to many projects, including one of the best explanations of takt time that I have read. The book won a Shingo Prize. After reading it, I agree that it deserved the award.
Image courtesy of Productivity Press