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October 30, 2014
If lean process improvement has become a mainstay in the healthcare industry, lean design follows as a close second.
Organizations are increasingly expecting design professionals to better understand their business processes. They are also including “lean design experience” in their selection criteria.
When and how does a design firm initiate the lean design process? The logical answer would seem to be immediately upon award of contract, to employ lean workshops and tools to create the expected value-added spaces.
But what if the project is in an existing space? Or, what if the design is inhibited by a “standard” layout? Can lean design be successful when deployed under less-than-ideal conditions?
The VA and lean design
When CollinsWoerman was asked to run three lean workshops for the Veterans Administration in Palo Alto, California, we jumped at the chance to help the agency develop a new clinic design.
The VA Palo Alto Health Care System has been recognized as a national leader in improving veterans’ healthcare. We were already familiar with the VA’s new Patient-Aligned Care Team approach to veterans’ health as part of the team that authored the PACT design guidelines.
The PACT model is being implemented across the nation in all VA medical centers and clinics, and new clinics are being designed around it.
PACT is a care team assigned to each veteran and his or her family. Each primary care team consists of a physician, nurse care manager, clinical staff assistant and administrative staff member. Other specialties, such as behavioral health, dermatology or cardiology are brought in when required.
PACT is the VA’s version of the medical home care model, where the patient “pulls” the services needed to diagnose and treat his/her condition. If a patient has multiple conditions, they will be seen by their providers on that day. Stated another way, services are brought to the patient.
Adopting Group Health’s model
A notable example of a medical home clinic design is Group Health Cooperative’s Puyallup Medical Center.
CollinsWoerman partnered with GHC to use their “integrated care and facilities design” process for the Puyallup Clinic. This lean method combines operational improvement with building design. The result is an on/off-stage design that separates the flow of patients and providers. GHC tested the design in full-scale mock-ups and lean workshops.
Now in its second year of operation, GHC validated the success of this approach by eliminating patient waiting and increasing doctor “face time” and the total number of patients seen. It’s no wonder that when VA leadership first visited the new GHC clinic they concluded that the design would be a perfect fit for their new PACT operating model.
VA Palo Alto leadership’s vision was to incorporate Group Health’s operating improvements and facilities design features into the planning of the VA’s Monterey and San Jose clinics. The resulting clinic designs used many of the key design concepts developed for GHC. However, one element of the planning process was missing: the lean design workshops attended by front-line clinic staff and patient advocates.
Without the process improvements achieved in the lean workshops, how would doctors and nurses know how to “operate” in their new clinic? Would they move into their new spaces and practice the way they always have?
Stop the line!
We took a step back and considered the options. Our challenge: How do we employ lean design under these conditions? Solution: Redesign the lean workshops to “test” the proposed designs.
We conducted “3P” style workshops for both clinics. The 3P (production-preparation-process) workshop motivates teams to identify waste and document current-state processes. It also inspires teams to develop new, innovative future-state processes.
Normally teams would then create layouts to support their new processes. However, with the clinic floor plans already developed, the teams focused their energy on testing the plans using simulation tools.
2-D simulation involved testing the “flows of medicine,” which include patients, their families, providers, information, medication, supplies and equipment. The teams simulated a patient visit by tracing each flow on their table-top plans. The teams also used an appointment waterfall chart along with the plans to understand clinic capacity and throughput.
After simulating patient arrival, check-in, rooming, the provider’s visit and check-out, the teams identified flow bottlenecks and proposed both process and plan refinements.
Building the mock-up
We didn’t stop there. The workshop teams tested their PACT skills in a full-scale mock-up constructed in a warehouse near the NASA Ames Research Center in Mountain View. The mock-up included “on-stage” patient corridors and exam rooms and “off-stage” team work areas.
We designed role-playing simulations for several types of patient visits. With each reenactment, team members were better able to connect PACT operations with the proposed clinic design. Each team member was encouraged to provide design feedback on Post-it notes anywhere in the mock-up space. In one week over 500 comments were posted.
Since the initial workshops were completed, the mock-up has been visited by staff from existing VA clinics within the Palo Alto Health Care System, and by VA representatives from across the United States.
Architect Doug Grove is a Certified Kaizen Leader at CollinsWoerman Architects in Seattle. He has over 20 years of experience in healthcare facilities planning and development. Using the lean 3P process, he developed a unique lean design methodology that integrates process improvement with facilities planning.