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Henry Ford, inventor of the mass-production assembly line, was wrong. Taiichi Ohno, innovator of the “lean” Toyota Production System, was right. Particularly when the topic, and point of application, is the design and construction of healthcare facilities in the 21st century.

To support the lean, decentralized, service-matrix approach to healthcare delivery, a new design vocabulary revolves around four concepts: factories, hotels, condominiums and marketplaces.

As an innovator in healthcare design, my challenge is to continually reinvent how we approach clients’ projects. In the last 30 years, a methodology for the design of hospitals based on Ford’s assembly line and batch-oriented principles has enslaved clients to an architectural approach that consumes valuable time and energy, without enhancing the patient experience.

Today, hospitals must operate in a world in which new technologies, clinical techniques, work processes, patient expectations and cost restrictions have shown Ford’s concept to be flawed. Instead, Ohno’s streamlining of production techniques to eliminate waste in human effort, materials and time— dubbed “lean manufacturing” and “lean techniques” by James P. Womack, Daniel T. Jones and Daniel Roos as in their 1990 book, The Machine that Changed the World—are being applied to the design of new healthcare facilities, with stunning
results.

Those results include reduced energy-use and costs for hospitals; improved service and safety for patients; and engaged and motivated employees. In other words, today, the task for healthcare architects and hospital facility managers is to design continuous workflow processes for staff that create a seamless care experience for patients. The way to accomplish this task is through a “lean” approach to design that eliminates waste at every possible level.

As a healthcare designer, my goal is to leverage innovative thinking, such as “lean processes” in manufacturing, to revolutionize patient and employee expectations of health care. Over the years, in collaboration with several clients, I have pioneered a pre-design process that applies a lean approach, which focuses on the patient experience, staff empowerment and the elimination of non-value- added (wasteful) steps during patient care. The result: A cultural transformation in healthcare delivery and the design of hospital facilities.

Only when the pre-design phase is complete, do we translate our findings into an architectural program that embodies the physical spaces required to support and sustain that lean healthcare delivery. In other words, the architectural design is about matching the expectations we have discovered during pre-design with a facility design that embodies the lean approach to customer service.

Pre-design: Value Orientation and
Cultural Transformation
One of our first innovations when approaching the design of a new or replacement healthcare facility is to define value from the perspective of the patient. To accomplish lean design, we need to hear the voice of the customer: Their likes and dislikes, disappointments and delights. So I have pioneered a creative method by which we work with hospital staff to investigate a variety of patient stories.

Under our direction, the hospital staff collects, writes about and then acts out vignettes or skits that reflect these patient stories. One of our most popular vignettes is what we call Bone and Joint Jeopardy, in which the staff conducts a lively question- and-answer game about the patient experience.

After these vignettes, we create a mind map of ideas about the varieties of patient experience, followed by brainstorming sessions in which we explore ways in which staff could work differently to always focus on patient delighters, not patient disappointments. Underlying these explorations remains a variety of patient needs: to respect their time, increase safety while reducing medical error, promote a people-to-people interface between patients and staff, and create a healing environment that connects mind, body and spirit.

This patient-oriented process not only reinvigorates the core values at the heart of healthcare delivery. The process also refocuses and re-energizes staff about the reason they became healthcare professionals in the first place: To help patients. During this value- defining process, we have often found staff members begin by talking about why they do not provide good service, and name all the reasons why good service is not possible. By the end of our sessions, they have become patient advocates. Their defensive mechanisms have melted away, they have reinvented their professional selves, they have recommitted to their healthcare goals, and they are looking at creative ways to accomplish those goals. In other words, this process acts as a change agent. As people are culturally transformed, they begin asking for a facility designed to achieve the outcomes that best serve patient safety and well-being.

A second innovation we have incorporated into pre-design is a process by which we create a value-stream map of daily activities inside the hospital. Working closely with staff, we identify all of the actions required from the time a patient is admitted, through diagnosis and treatment and discharge, and even during follow-up. This is an immensely detailed process that results in a complex matrix of department-allocated activities, product dispensation and technology use.

With staff, we examine the matrix with a fine-toothed comb. We ask how many of those steps, tasks and procedures really provide value to the patient. We ask which are done simply out of habit. We then examine where and when we can replace non-value-added steps with a different function, technological improvement or change in processes; and we eliminate all non-value-added steps.

Having reduced, transformed or eliminated all non-value-added activities and products—or waste—from the healthcare- delivery process, we have created a “lean” value-stream map that indicates a high-value customer experience. We then transform that value-stream map into an architectural program, with physical spaces that support and enhance this new, lean approach to healthcare delivery. It is a given: When you design around lean concepts, you design a safe environment.

Innovating a Lean Design Vocabulary
Because of this pre-design process, we have discovered that the assembly line approach to healthcare, with its emphasis on batching and repeating the same tasks again and again, is no longer the service-delivery environment that staff desire, patients need or facilities can economically sustain. Instead, we have found that the safer, leaner, more costeffective healthcare environment incorporates a decentralized, integrated service- delivery system.

In this integrated system, services are oriented around the patient instead of requiring the patient to travel to the services. So we design for point-of-care testing, in order that the patient can be diagnosed immediately. We design patient rooms to be identical, so in case of emergency the beds, medical gases, patient monitors and medications are always located in the same place, thus creating a more patient-safe environment by eliminating the possibility of staff error.

Each patient room is also its own work cell, which staff members regularly visit to complete charting, dispense medications and restock supplies. As a result of this patient-focused design, staff members are less distracted and can focus exclusively on the patient at hand, which results in less staff error and less patient stress.

Accordingly, we also design for collaborative staff teaming, a more cellular, integrated and interdisciplinary way of serving patients. In this service-delivery method, team members move from patient to patient, instead of the patient traveling from room to room. Instead of designing a storeroom down the hall, we design so supplies are regularly deployed to within two feet of staff.

To support the lean, decentralized, service-matrix approach to healthcare delivery, we have created a new design vocabulary for hospitals created around four basic concepts: factories, hotels, condominiums and marketplaces. Within the hospital, all of the staff- centric spaces (nurses’ stations, surgeries, procedure rooms), where staff gathers to administer specialized services for patients, are the “factories.”

Rooms for all-day patients are called the “hotel.” After the patient checks in and has their procedure, they retire to this room for recovery. Like in a hotel, the patient “rents” this comfortable, temporary space as a home away from home. In contrast, the “condominium” is for the in-patient who requires a longer stay. Our design emphasis in these areas is on space for families to gather, creating a home-like environment and providing healing views to the outdoors.

In the “marketplace” we locate the physician offices and diagnostic areas. This is often the clinic area, which patients visit for assessment and to purchase services. Because this clinic may be competing with other clinics for customers, our design must stress convenience and accessibility—or patients will self-select to go elsewhere.

By creating these four distinct zones within a hospital, we have further tailored the healthcare delivery process to eliminate waste, improve patient safety, reduce staff error and enhance the patient-care experience. As the numbers show, lean design yields results.

Lean Results:
Increased Safety and Cost Savings
One of our prototype lean-design projects is Sutter Health Care in Elk Grove, California. Our pre-design process resulted in a facility that reduced staffing by 40%, patient wait times by 50%, building square  footage by 30% and energy consumption by 25%. For Virtua Health’s Voorhees Replacement Hospital in Voorhees, New Jersey, we also implemented these lean concepts to improve patient care and safety, and our strategies and results have been discussed in numerous publications.

St. Joseph’s Community Memorial Hospital in West Bend, Wisconsin, on which we teamed with several other architectural firms during site-planning and pre-design, is reportedly one of the most patient-safe hospitals in the country. As we have discovered, designing with lean concepts results in a safer healthcare environment.

Using lean concepts, Ohno persuaded Toyota to work more efficiently and effectively, creating a culture of staff empowerment in the process, while boosting financial performance and customer satisfaction. Similarly, the lean approach to healthcare design we have adapted from Ohno’s concepts creates a culture of empowerment and patient advocacy in healthcare staff, identifies and eliminates waste in service delivery, reduces costs, increases efficiency, and improves safety and the overall patient experience.

Healthcare clients across the country have begun to embrace the lean predesign process with stunning success. It is only a matter of time before lean problem- solving strategies are embraced by other clients representing a spectrum of for-profit and non-profit organizations.

Kurt G. Spiering, AIA, ACHA is healthcare vice president/principal for HGA Architects and Engineers.

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