Lean Team Engagement

Improving Healthcare Design

Jennie-Mae Evans

Jennie-Mae Evans

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Jennie-Mae Evans promotes family-centered care and operationally efficient environments by integrating her healthcare experience into the design process and contributing to evidence based design in the built environment. President of the Nursing Institute of Healthcare Design, Jennie is passionate about improving the environment of care for patients, families, and providers.

Lean planning and design goes beyond traditional design by gaining the voice of the customer and involving the customer in actual design development. A successful Lean Design project requires strategic pre-planning to choose the right team members, design the process and provide tools to envision the new work environment.

Healthcare facility design is evolving to use lean principles in more phases of the design process. To date, the majority of the lean principles and tools have been used during the construction process which has demonstrated to reduce waste in the schedule and save the owner money. When Akron Children's Hospital recognised the need for additional critical care beds and emergency department rooms, the decision was made to integrate the latest lean principles in the pre-design stage. Using lean principles in pre-design required the skill set of the hospital's operational excellence Lean Six Sigma team. It also required hiring a design team for their understanding of lean principles and the need to include the voice of the customer in the early phases of design. This article provides the five key elements of preparing for lean operational planning in the building design process. This method will break down the steps your hospital team will be taking during a lean design effort.

The focus

Akron Children's Hospital (Akron) is one of the largest paediatric facilities in Ohio and cares for more than 600,000 children annually, including over 60,000 children in the emergency department and 1,800 neonatal intensive care admissions. With that volume, the emergency department had outgrown its facilities and the model of four-patient pods in the NICUs needed to be updated. In 2011, Akron recognised the need fora new patient tower to include additional and updated critical care space to match the trend of single patient rooms.

In 2008, Akron developed a new department dedicated to continuous improvement and operational excellence using Lean Six Sigma methodology. Akron leadership viewed lean methodology as a perfect match to create the vision to plan this new patient care tower. Lean activities seek to drive out waste in several forms including defects, overproduction, waiting, non-utilisation of employee skills, transportation, inventory, motion and excessive processing waste all with the intent of providing value to the end-user or customer.

The primary principles of lean include:

1. The Customer

Determining the right mix of people for a design team is a challenge for any hospital leader. Design is a long and demanding effort and requires early adopters, cheerleaders, communicators and influencers. Leadership needs to look at the cross section of the team and consider a mix of formal and informal leaders along with introverts and extroverts. It is important to create a culture that gives the team the opportunity to develop and grow with the project.

The philosophy of lean depends on the voice of the customer to successfully meet the customer's needs and expectations. In facility design there are multiple customers who all add equal value to the project. Patients and families provide their perspective and expectations of the facility, and it is equally important to hear the voice of the physicians, nurses and ancillary staff including pharmacy, lab, rehabilitation, social workers and case managers who will be working within the space. Materials management, security and environmental service staff, who bring supplies, maintain and protect the space, also need involvement so they can work through their processes in support of the new space.

Although the design team can become large very quickly, it is important to bring key stakeholders in at the right time. Design process events must be coordinated with busy providers and tight staffing schedules. Akron scheduled design events three months in advance to optimise the availability and participation of medical staff. Even with the best planning, emergencies arise making flexibility important. Working with a surgeon's office staff to be sure he or she is available when their specific operating room design was being discussed or holding specific equipment or design presentations after office hours are examples of the flexibility required.

2. The Preparation

Preparation of the clinical team for this work is as important as selecting the right members for the team. Critical to the use of lean concepts is for the team to have a good understanding of lean principles and tools as well as providing a common language for all participants.

For Akron's new hospital tower project, all design team members were required to attend a 2-day/20-hour Lean Boot Camp. The Boot Camp consisted of both didactic and hands-on learning. Mindful of the principles of adult learning, the Boot Camp instructors utilised a variety of instructional tools and introduced learning by doing activities often during the two eight-hour sessions. Participants were introduced to a mix of lean based Power Point presentations and video clips of actual lean tools in use such as huddles, 5S (lean method of organisation) implementations and visual management examples. Learning by doing was accomplished with the use of games to emphasise the lean concepts of one piece flow, standardisation and the advantages of visual management to create and enhance flow. A common understanding of lean principles and language was developed for the team.

During Boot Camp, a foundation of lean principles and tools were shared and adopted to aid the team in their process improvement activities. The learning in these sessions included the principles of lean related to: the voice of the customer, the eight wastes of healthcare, flows associated with healthcare and respect for people at all levels of the organisation and the construction team. The Boot Camp also included a review and hands-on learning of the lean tools. The tools included fishbone mapping, one piece flow versus batching exercises, value stream mapping and takt time calculation (demand/hours of operation).

Value stream mapping

The goal of the Lean Boot Camp was to encourage the team to have a true and deep understanding of their current state and to develop the tools and skills needed to transform into the future, ideal state the team envisioned. That future state would be the elimination of the identified wastes most prevalent in facility design including the wastes of motion, transportation and inventory management and process. The Boot Camp is educational and motivational for the attendees and energises the participants to make changes in their work place.

3. The Future State

Establishing guiding principles and Conditions of Satisfaction (COS) early in the design process is a fundamental requirement used throughout the duration of the project. The principles drive decision making, establish priorities, and determine what is in and what is out of the project. COS is a lean term often used to describe what will make the project successful for the team, which included clinicians, design team, consultants and contractors for Akron. The COS are also used to describe overall project success and to establish baseline metrics.

At Akron, the team's guiding principles were used consistently to determine the best room type adjacencies, the correlation between patient satisfaction and operational process changes and among staff efficiency, elimination of waste and operational processes. For example, the NICU design team adopted a guiding principle that all patient rooms would have an exterior window. Knowing the NICU needed 75 beds based on their volume and length of stay, and knowing the building currently planned did not allow enough parameter space, the architect designed an alternate of the building for the team.

Once the team has been prepared and educated, the design work begins.

Some of the changes that were identified to improve the process included:

The design team, armed with the knowledge and tools of Lean, can now objectively assess their current state. For example, they can identify and measure the waste of hoarding patient care supplies in multiple storage areas around the unit. Using takt time, they can calculate how many rooms are actually needed because they have measured the current amount of time the patient occupies the room and the number of patients that enter for care. The team begins to realise that more and bigger is not always better and are able to see the future potential of what their design work can contribute to the patient and staff experience.

Using a blank sheet of paper representing the unit and paper cutouts representing spaces within the unit, the team went through the design process. By doing so, they appreciated the concept of adjacencies and created procedural flow by linking key spaces, thereby, reducing the amount of walking for staff and reducing the time transporting supplies and equipment.

4. The Venue

Individual room mockups have been used as a design tool in building projects for some time. Akron went a step further and used a full-scale department mock up for each department. Patient care scenarios, including family representatives, were used to identify adjacencies, space requirements and ease of people and material flow.

Bringing the medical staff, care staff and support staff into this type of design environment can be challenging. For full size mock up design work, the venue is often a warehouse and the space is very foreign to the healthcare staff. Warehouses are large, often cool and use lighting that is much different compared to their daily work unit. Beyond the actual design work, there is a tremendous amount of learning and discussion. Planning must include amenities to keep the team engaged and energetic, including meals and snacks, access to light and outlets for creativity and energy are essential.

Breaks should be short and frequent and include a game or activity that keeps the team fresh. Adequate technology links must be available to attendees in orderto access the hospital for communication needs. In addition, Akron found it beneficial to set up a classroom environment for team learning, discussion and facilitation activities during the full scale mock up sessions.

5. The Transformation of Plan into Reality

The clinical design team was chosen not only for their clinical expertise, but for their ability to communicate and lead. With design complete, the real work of putting operations in place within the department begins. In his book, 'Managing Transitions: Making the Most of Change,' William Bridges says change is situational and easier to plan for than the transition that people go through moving from the current state to the new or future state. Akron, remaining true to lean principles of engaging the front line worker, implemented a change engagement strategy to ensure transition success.

The nursing director of each department, along with two to three other nurse leaders, met with an internal organisational effectiveness leader to outline the work to be done. In conjunction with the architectural team, a four-hour work session outlined the milestones that needed to be accomplished to fill in the gaps between the current state and the future state. In addition to identifying milestones, a timeline was created with the milestones so all of the work was centralised in one location. This was used by the management team as well as the unit specific staff to see how the unit's progress was advancing. Examples of this include the human resources team who reviewed the organisational structure and identified how new job descriptions or positions were required. Another example was identifying the training required for new equipment or technology. Documenting key milestones for these decisions and others on a timeline provided the department director and managers a more detailed work plan which became manageable and streamlined the information overload.

Additional responsibility and expectation for participation on the design team is sharing the information learned with those care team members remaining on the unit. Akron team members were creative in making that connection with their peers. Newsletters were developed with photos and plans that could be posted and shared. Town Hall Meetings were held for all shifts to share the activities of the team and to elicit ideas and feedback. Regular communication with all staff members proved to be well worth the time and effort invested because it helped foster excitement and engagement within the entire hospital staff.

Mentoring was provided by Akron's leadership to give all staff the opportunity to address their concerns with the new facility. Some of their concerns included how changes to the private patient room in the NICU would alter workflow, teamwork and their ability to see one another. Providing opportunities for discussion gave staff the ability to identify their concerns and allowed management to strategically address them.

The Value

Lean learning and application does not stop with the actual design process.

The result of lean methods in pre-design efforts provides an environment that is attentive to the patient experience; something every hospital desires to achieve. The innovation achieved as a result of teamwork is phenomenal when the leadership of a hospital decides to invest in its staff. In the book 'Patients Come Second: Leading Change by Changing the Way You Lead,' authors Paul Spiegelman and Britt Berrett state that excellent patient care begins with ensuring the culture of care is implemented with employees. Using lean principles in design initiates that culture and brings together a team that recognises their opinion matters and that their employer recognises them as offering value to the patient care environment.

Over the past twenty years, the look of healthcare facilities has undergone major changes. The once stark walls with minimal family accommodations have been transformed into a warm, welcoming environment for everyone. Family-centred care has paved the way for families to be welcomed in all areas of the hospital. The family's participation in the care of the patient has also changed becoming both positive and critical for optimal patient outcomes. Using lean principles in design creates the environment and the culture to promote a patient-focused, family-centred care environment. Akron would not have done it any other way.

1. Identify what creates value in the eyes of the customer
2. Identify the steps in the process and look to eliminate the waste
3. Create value by adding steps that enhance the value for the customer
4. Create flow by the pull from the customer
5. Continuous, ongoing improvement