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July 26, 2012

Lean design is different for every health care project

  • Three new buildings show how the process can be used to the reach the most-efficient design outcomes.
  • By BARBARA ANDERSON, MARK GESINGER and JOHN MESS
    ZGF Architects

    Photo courtesy of ZGF Architects [enlarge]
    Potential floor layouts for a new Seattle Children’s Hospital building were first tested using full-size mock-ups built in a warehouse.

    Lean design in a health care setting is an approach informed by a commitment to continuous process improvement and waste reduction. It is motivated by the needs of the patient and seeks to provide the highest quality care while reducing costs.

    Integrating these principles into the design of health care facilities can generate positive results in productivity, cost, quality and timely delivery of services.

    There is a lot of information in the marketplace about lean design, what it looks like and the specific results it yields. However, no lean design process is the same.

    Lean is not a topical application of trends of the day. At its most basic, lean design is a holistic, integrated design and discovery process aimed at providing the most operationally efficient patient-centered health care environment possible.

    Based on the needs and mission of the organization, lean requires reevaluating and reorganizing processes to yield the best outcome given the resources available. The process requires a willingness to let go of accepted knowledge and break boundaries to achieve something that exceeds expectations.

    Everett Clinic

    The new 60,000-square-foot Everett Clinic at Smokey Point, which opens on Sept. 4, will provide the largest offering of specialists outside the Everett Clinic’s main campus.

    Services include a primary care clinic, walk-in clinic and 22 clinical groups, along with digital imaging, laboratory services and physical therapy. Planning the facility provided the opportunity to carry out large-scale lean, work flow and cultural changes to create an operationally efficient and patient-centered care model.

    To meet an accelerated project schedule, a team including ZGF Architects, Alliance Project Advisors, and Joan Wellman and Associates held a series of design events. They included monthly conceptual design workshops that focused on the overall vision for the new clinic. The idea was to create a new model of care that improves operational flow, function and efficiency.

    The team worked with the Everett Clinic’s internal process-improvement system team, administrative leadership, managers, nurses, medical assistants, technicians, physicians and patients using a hands-on, cross-functional approach. A key element of the lean design process involved engaging all stakeholders, from the CEO to the custodial staff, in decision making.

    The lean workshops identified key design and process improvements to meet objectives such as maximizing flexibility, sharing support, shortening patient visits, and reducing non-patient care spaces by 23 percent.

    This process continued during schematic design and design development, providing flexible and continued evaluation of the design. Full-scale mock-ups of patient and caregiver spaces acted as a laboratories to create, test, evaluate and modify prototypes. Various patient and support flows were traced on paper over the design to confirm that goals and targets were met.

    Exam rooms were designed to be larger than the Everett Clinic’s standard 8-by-10-foot rooms, a change made possible by designing flexible pods that can be used by multiple specialty groups. The design reduced the total number of exam rooms by 25 percent.

    The exterior of the two-story building is constructed primarily of naturally finished tilt-up concrete, which was easy to erect and minimized scheduling time. Lean building materials provided an opportunity to achieve a functional design that connects the building to the natural surroundings. Lean construction methods saved time and money that can be funneled into health care savings for patients.

    Seattle Children’s

    Next April Seattle Children’s Hospital will open Building Hope, a 330,000-square-foot building that will house a new emergency department and 80 single rooms for cancer and critical care patients. Building Hope will also have room to add 112 single patient rooms in the future.

    Children’s is an early adopter of lean process improvement. Before design began, ZGF, Seneca Group, Sellen Construction Co., Joan Wellman and Associates and Children’s internal continuous process-improvement group worked together to organize over 20 lean design workshops, which were held with hospital leaders and staff, patients and their families. The workshops were used to identify design objectives, address campuswide issues such as departmental space deficiencies and parking, and determine best-case scenarios for operational efficiencies.

    During the workshop, groups identified their primary factors in the success of any design outcome: comfort, satisfaction, patient experience, and patient and family safety. Exercises to map the flow of materials and information were used to track movement within different service lines, departments and overall hospital operations. The exercises also helped evaluate different scenarios for placement of key departments, hospital services and parking.

    Full-size floor mock-ups were created in a warehouse and used to test scenarios, validate design assumptions and refine proposed solutions, which ultimately resulted in a consistent template for floor layout. This design maximizes flexibility, using overlapping systems and spaces, thereby reducing underused areas dedicated to singular programs.

    Virginia Mason

    In May, Virginia Mason Medical Center opened an integrated procedural center in its Jones Pavilion. The center has 12 admit/recovery rooms, three gastrointestinal procedure rooms, two interventional radiology procedure rooms and ancillary spaces.

    In support of the Virginia Mason Production System (VMPS) — a management method that seeks to continually improve how work is done — the team identified methods to eliminate waste and inefficiency, while keeping the patient experience at the forefront. The lean design process was performed via a three-party integrated program delivery agreement that included risk/reward incentives for ZGF and the contractor, Turner Construction.

    A weeklong event using 3P, a multidisciplinary design method that stands for Production Preparation Process, resulted in integration of three separate services into one department, providing patients a single location to receive services for a variety of treatment needs.

    During the iterative design process, the team consulted a broad spectrum of stakeholders including patients, physicians, nurses, procedural technicians/technologists, anesthesiologists and other team members to facilitate continuous flow throughout the patient care delivery continuum in order to optimize the patient experience.

    Full-scale floor and room mock-ups allowed stakeholders to refine and optimize the design and operational efficiencies. Outcomes of simulations included requirements such as flexible admit/recovery rooms, separation of procedural documentation space, and dedicated physician work spaces.

    The VMPS design process also supported the project’s integrated program delivery model. During full scale mock-ups, Turner and ZGF were able to identify and resolve construction challenges that could potentially cause scheduling delays during construction.

    Across project scopes and budgets, lean design considerations should be viewed through a lens that considers the “seven flows of health care” and their effect on efficiency. The seven flows include the flow of patients, clinicians, medications, supplies, equipment, information and process engineering.

    This approach provides a framework that will benefit staff, physicians, patients and their families through the next generations of needs.


    Barbara Anderson is an associate partner at ZGF Architects and holds a master’s degree in nursing. Mark Gesinger is a senior medical designer at ZGF, and John Mess is an associate partner with over 33 years of experience across a wide range of health care project types and services.


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