Lean Healthcare Exchange

Redefining what patient-ready means for a new facility’s opening day

If you have ever moved into a new home, you have experienced the same level of planning and organization typically involved in opening a new hospital facility. When you move, I would surmise that your basic packing and organization tenets are similar to visiting a national forest – “pack it in, pack it out.” Whatever came from your old kitchen gets packed into boxes marked “Kitchen,” and is then moved to your new home to then be unpacked and stored wherever you see fit.

In your home, you may be the only cook in your kitchen, so individual organization preferences are a fine tactic. A little disarray is okay since you’ve got great kitchen cabinets with solid wood doors to hide things behind. Chances are also good you probably only have one kitchen, so there is no need to plan and organize multiple spaces in tandem.

In healthcare, imagine where the problem lies in that move-in strategy: Many caregivers, many users of common spaces, many common spaces. Depending on who is unpacking boxes of new supplies – or old supplies – there are an infinite number of possibilities for where the basics should go. Often they are squirreled away arbitrarily behind cabinet doors which offer only an outward semblance of organization.

Wouldn’t it make the most sense to have all of these common spaces, with common purposes, standardized and organized identically, with common visual cues for locating items? Think about it this way: have you ever had to make a meal in someone else’s kitchen? Where are the measuring cups? Plates? The saucepan? Unless you were the lucky soul that unpacked the kitchen after a move, you’re going to have to search or ask. It takes a while to get acclimated to such an unfamiliar environment. If a caregiver is out of her comfort zone, on another floor or in another department, she will likely find each storage area organized either slightly, or drastically, differently. To complicate matters further, nothing is visually identifiable from a distance due to cabinet doors and a lack of labeling.

This naturally leads to confusion, searching, and ultimately, less time spent caring for the patient.

My “a-ha” moment came when I recently had the opportunity to participate in a new hospital’s move-in preparation engagement, just prior to opening day. The scope of HPP’s engagement involved preparing the hospital for a smooth opening through mass rollout of a workplace organization plan — every storage location imaginable, planned to the smallest detail. Lean Healthcare workplace organization principles were used to facilitate the creation of identical function and storage arrangements in medication, nourishment, exam, treatment, and supply rooms, as well as nurse stations, ED bays, ORs and any department with multiple same use areas.

We quickly found that some of the most beautiful, solid, and expensive portions of the new construction were only conceptually functional – non-uniform, built-in casework, counters and cabinets. In this facility, the upper casework shelves were too high for most caregivers, and issues arose in attempting to organize supplies in the deep cabinets and drawers.

Casework is traditionally designed into a room in the remaining space, almost as an afterthought.  The typical end result is a lack of uniformity of sizes of cabinets and drawers from room to room.

However, we were given a task to complete, and weren’t about to let this casework get in our way.

We developed a workaround to the casework issue by using Lean Healthcare workplace organization principles. We implemented an on-site fabrication team that worked with the caregiver’s input to determine storage arrangements needed for specific supplies in each type of identical room or area.  We were able to resolve the majority of the issues and create uniform work and supply areas with just a few tools and well-chosen organizational support devices.

New hospitals still in the design phase or facilities simply needing a remodel have the opportunity to design spaces that promote flexibility and standard work. This can significantly improve standardization of storage across departments or identical rooms.

As was the case with HPP’s move-in project, when you have built-in casework, you must adapt the work processes to the facility. While the solution was ultimately a workaround to total adaptability, the workplace organization strategies allowed for the best possible use of the casework. We were still able to change the facility to support the process, rather than having to change the process to adapt to the facility.

This week’s blog was written by Renee Hawk, with creative input from teammate Jason Baldwin. Renee, a senior associate with HPP, brings 14 years of corporate management experience with a strong record of achievement in Healthcare Facility Design during her 18 years with Herman Miller Healthcare. She holds a Bachelor of Arts degree in Environmental Factors and Interior Design from California State University at Long Beach, with advanced training in healthcare design, Lean process improvement and project management. Renee also holds LEED AP and California CID certification.

Jason Baldwin is a senior associate with HPP with a deep background in healthcare marketing and creative services. He previously served with an international healthcare architecture company as the firm’s marketing pursuit team manager.

As a nurse with many years “in-the-trenches”, one of the most frustrating realities in the hospital is the inconsistencies associated with relatively standard spaces and work tasks. Two identically functioning rooms on the same floor such as a medication room can have unique features and inventory that force wasted motion and effort in order to complete the routine task of medication delivery.

Why can’t highly repetitive spaces such as a medication room, nourishment room or even a med-surg patient room be truly standardized so that no matter where you are deployed to work, you are instantly familiar with the environment and standard work is accomplished without the waste of searching for supplies and equipment?

There are many challenges associated with not only creating facility-wide standard work but more importantly sustaining it. Unless a facility was designed using Lean Design principles such as standardization, room sizes and shapes are rarely identical, forcing differences in work flow, cabinetry configuration, and ultimately storage capacity. Without established standards and a strategy to maintain them, rooms with the same purpose have general similarities but lack the structure necessary to sustain standard work conditions within a Lean Healthcare facility. Many times each day a single trip to a medication room turns into much more than the clinician bargained for – after rummaging through every cabinet and drawer for a syringe that was supposed to be routinely stocked in the room, the nurse finally gives up and walks to another medication room or the clean supply room to complete what should be a simple medication administration task.

Without a doubt, designing new construction using Lean Design principles is ideal. However, Workplace Organization can help mitigate the lack of physical standardization plaguing the healthcare environment. HPP recently got the opportunity to tackle both standardization and sustainment on a large scale by using Systematic Workplace Organization strategies in a new 125-bed community hospital. With military style planning, 40+ highly repetitive prototype rooms were identified and developed with the input of bedside caregivers.  The prototypes were then mass produced through a cloning process that spread workplace standardization over the entire facility using 5S and Visual Management principles.

As the hospital prepares for its ribbon cutting next month, the benefits and cost savings are becoming immediately apparent. Staff orientation to the new Lean environment is easier. There are fewer supplies in inventory than a facility of similar size and staff feedback regarding their satisfaction with their work environment is extremely positive. Most importantly, the hospital’s Lean Journey will continue forward on a foundation of widespread workplace organization.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

Our beloved principle of “standardization” is frequently put to the test in the Lean Healthcare Design realm when outfitting a large number of repetitive rooms. Even creating a standard which includes placing a low cost item such as a suction regulator in each med surg room can add up quickly.

Creating an ideal state most often includes the development of a standard. Sometimes the trade-off for standardization is lower utilization. Let’s use the case of the suction regulator to illustrate:

1. Safety – Immediate availability of suction is one of those clinical interventions that can be a critical and unexpected need. It definitely meets the safety criteria.
2. Convenience – In many hospitals, regulators remain in the “last-used room” location. The nursing staff launches a scavenger hunt when a regulator is required in another room without one in place. It is certainly inconvenient and frustrating when trying to set up for a new admission or change inpatient condition. Numerous travel steps can be avoided by applying one of several lean tools.
3. Patient type – One of our community hospital clients recently estimated that only 10% of their med surg patients required suction. This hardly justifies the case for a suction regulator in every room. In med-surg, certain types of patients will require suction more often. Depending on how much you are able to cluster these patients, utilization may be higher – making 100% standardization more appealing for a smaller area.
4. Cost – Initial cost is probably more than you want to spend, but it is non-recurring. With the proper lean tools in place, you can be sure that replacement cost will be minimal.
5. Attrition – Without lean controls, small devices such as regulators have a tendency to disappear over time. They are like socks that go into the dryer. Where they go is anyone’s guess!

What if there is no money in the budget to have a suction regulator in every room? In this case it becomes even more critical to have a Lean system in place. Below are just a few ways to apply Lean Healthcare Principles to the suction regulator dilemma.

• Create a dedicated location for a suction regulator(s) on each hallway with a kanban system for replenishment when the item is put into use.
• Use visual management principles to create staff awareness when the item is missing and requires action for immediate replacement.
• Establish a process to remove suction regulators from rooms at the time of terminal cleaning to return them to the inventory cue. This could even be built into a check list used by Environmental Services.
• To manage the “critical need” issue, place a regulator on the crash cart as part of the basic inventory to ensure that no one is ever caught without a regulator in a time of crisis.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

As hospitals and healthcare systems struggle to balance rising cost with reimbursement, capital investments such as building renovation and expansion must bring tangible savings through enhanced environmental and operational efficiency. Requests for expertise in Lean Design Services in architectural proposals or RFP’s are becoming very common.

It is true that new construction offers a unique opportunity to correct years of process workarounds and suboptimal space utilization.  Lean healthcare principles can be used effectively to guide the development of optimal future-state processes which can then be applied to create a supportive architectural design.  The opportunity for improved patient outcomes while reducing or eliminating waste can be unprecedented. Unfortunately, the benefits of Lean cannot be realized through Lean healthcare design alone.

Important considerations before employing Lean Healthcare Design:

• New facility design can support Lean processes, but it is essential that the organization’s leadership team be enthusiastically committed to beginning or continuing its lean journey toward waste-free work.
• Lean does not end with building completion. Lean healthcare processes must continually evolve after building occupancy and the design response must offer the flexibility necessary to accommodate change over time.
• The concept of “standard work” must be embraced throughout the organization at every level as part of its culture in order to achieve the full benefit of the Lean Design. This can be more difficult than it sounds. Department managers must agree to standardize work processes across departments. For example, unit secretary workstations and work processes are identical regardless of location within a facility.
• The comprehensive use of visual management tools and standard placement of supplies and equipment are necessary to promote and sustain Lean processes. Communication boards, visual kanbans, and designated parking spaces for mobile medical equipment promote seamless transitions between caregivers prevent staff from searching for needed items.
• Adequate staff preparation and Lean training is vital to patient and staff satisfaction as well as waste reduction. The staff must embrace the Lean processes that actually drove the building design. This cost is often underestimated.

If “going Lean” were easy, hospitals would no longer need waiting rooms. Nurses would not hoard supplies in the pockets of their uniforms and patients would never get hospital acquired infections. When a Lean healthcare organization can deliver healthcare in a supportive Lean environment, the successes achieved in the manufacturing world to eliminate waste and defects may actually be possible.

This week’s blog was written by Teresa Carpenter. Teresa is the Director of Lean Clinical Design with HPP and brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in theacute care environment, Teresa moved to Nashville where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Teresa assists hospitals and healthcare systems in all aspects of applying Lean to the master plan, design, and operational aspects of a facility design or clinical expansion. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

As Lean continues to take hold in Healthcare operations, more Healthcare Executives are requiring that Lean Flow be designed into their new facilities.  On the surface, this seems logical.  Streamlining patient, equipment, supplies, medication, nutrition, labs and work flows is hard to argue.  But how do Lean concepts really apply to the physical design of new facilities?  And how do we help clinicians and architects see that more and bigger are not always better, and can cause additional Waste?

I developed the following list of Facilities Design Implications as examples of how Lean Healthcare can help eliminate the 8 Wastes.  Applying Lean thinking to the Design, Construction and Operations of a new facility can save time, money and frustration not only to the new facility, but to the Design and Construction process as well.  Is it hard?  Yes.  Does it require vision and investment to apply Lean on the front end of a new facilities project?  Yes.  Are the short and long term (30 years or more) benefits worth it? Absolutely!

This week’s article was written by Dwayne Keller. Dwayne, MBA, MSME, holds the position of Vice President of Healthcare Performance Partners, LLC (HPP).  He coaches at all levels of Healthcare organizations, from CEO to front line staff to deliver improved outcomes via Lean. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

There are many ways to explain what Lean Healthcare is, leading to different definitions.  In the spirit of Lean principles, I submit the following brief description and definition of Lean Healthcare and invite your feedback.

Originally developed by Toyota after WWII as the Toyota Production System, Lean has become recognized as the premier process improvement system in the world.  It has gained traction in Healthcare due to significant improvements in safety, quality, lead time, and financials through the application of Lean principles and tools.  Lean engages all levels of the organization in the elimination of Waste in all processes.  The 8 Wastes in Healthcare are (please note the DOWNTIME acronym):

• Defects
• Overproduction
• Waiting
• Not Clear (Confusion)
• Transportation
• Inventory
• Motion
• Excess Processing

Definition:  Lean Healthcare is a structured way of continuously exposing and solving problems to Eliminate Waste in Systems that deliver Value to Customers (Patients).

As more leaders in an organization begin leading its implementation, Lean becomes their operating model.  Since Lean principles and tools apply anywhere there is flow (of products, people, or information), it can be applied to any process: operations, clinical, business office, and support services.

More recently, Lean Healthcare has been successfully applied to new facilities design, resulting in better space utilization, lower design and construction costs, and more efficient operations.

This week’s article was written by Dwayne Keller. Dwayne, MBA, MSME, holds the position of Vice President of Healthcare Performance Partners, LLC (HPP).  He coaches at all levels of Healthcare organizations, from CEO to front line staff to deliver improved outcomes via Lean. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

As a Lean Clinical Design Consultant with 10 years experience working along side well meaning hospital employees in the planning and design of numerous building projects, I have come to recognize the signs and symptoms of a very insidious infirmity. I have termed it Post Traumatic Space Deprivation Disorder or PTSD(D). It can dramatically distort reality, lead to improper allocation of square footage and interfere with project goals such as improving the quality of care and operational efficiency.

Just as is the case of the mainstream mental health affliction, post traumatic stress disorder, hospital caregivers have endured great difficulty, frustration, and even helplessness in performing their daily responsibilities. They have battled the inefficiencies of aging, antiquated environments with semi-private patient rooms, cluttered workspaces, and distant, small supply closets. When called upon to participate in the design of a new work environment, excitement can quickly turn into anxiety. Making decisions about process and space can be overwhelming even for lean thinkers.

Even under the most ideal circumstance, as when an organization is one to two years into their lean transformation, the typical design process focuses on floor plan development by individual departments which can create work process barriers for today’s extremely multidisciplinary treatment model. Left unchecked, PTSD can negatively influence attempts to reduce waste in the new environment and even contribute to the most dastardly budget buster; scope creep.
The symptoms associated with PTSD are remarkably similar to those of its medical counterpart. Early recognition and aggressive treatment is essential in overcoming the negative effects of PTSD.

Symptoms of Post Traumatic Space Deprivation:

• Flashbacks – Valiant attempts to recreate a perceived happier time in the past (like medical school or a previous work situation)
• Bad Dreams – Exaggerated memories of the rare or occasional occurrences when limited space or capacity caused delays in patient care delivery. (”Feeling like you must build the church to accommodate the crowd on Easter Sunday”)
• Frightening Thoughts – An uncontrollable fear of not having enough storage space, windows and bathrooms.
• Rationalizing – Creating endless logical reasons for maintaining sub-optimal or dysfunctional current state processes. (Holding on to “the way we do it now”)

Steps to Overcoming Post Traumatic Space Deprivation:

1. Get on the Lean Path and Stick to it! – It is never too late to begin transforming culture and process using lean thinking. One word of caution – Lean design is a little like purchasing a size 6 wedding gown on clearance in January and vowing to lose 50 pounds before your June wedding. There are no refunds on new construction if you have “fallen off the lean wagon”!
2. Value Stream Map Current State Processes – Value stream map current state processes and pay special attention to understanding how the environment may have shaped process. Identifying existing building barriers will prevent them from being transferred in the new environment.
3. Perform Direct Observations – There is no substitute for going to the Gemba or where the work is done. It is rare that the reality of direct observation matches how the process is perceived to be working.
4. Utilize 3P (Production Preparation Process) – Develop ideal future state processes by focusing on waste elimination in process design. Lean processes can then accurately inform the architectural design.
5. 5S the Current State Environment – The exercise will not only give design participants a more accurate picture of how much space is really necessary to accommodate supplies and equipment in the future state, it will improve efficiency and staff satisfaction with the existing work environment.

PTSD can be overcome through diligent application of basic lean principles. Design team participants can redirect their natural human tendencies toward more value added design solutions that focus on healthcare’s most important customer – the patient.

This week’s blog was written by Teresa Carpenter, the Director of Lean Clinical & Facilities Design at HPP. Teresa brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in the acute care environment, Teresa moved to our Nashville area where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Among these projects, she was the lead planner on the nationally recognized St. Joseph’s Hospital in West Bend, Wisconsin, the world’s first hospital designed to reduce medical error. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

30 years from now, what will people working in your aging hospital be asking

No leader would ever intentionally institutionalize Waste.  Unfortunately, it is happening every day as new Healthcare facilities are being designed and built.  As our population ages, new construction and expansion of existing Healthcare facilities is increasing at a rapid pace.

“It looks nice, but look at all the walking we have to do every day!”

So, why would Waste be “designed” and “built” into a new facility, and literally be institutionalized into the bricks and mortar for 30 plus years to come?  The answer is that Healthcare leaders who must make the design decisions don’t realize that they are designing Waste into the new facility.  Even if they have been exposed to Lean Healthcare or started a Lean Transformation at their facility, when choosing between options put in front of them by the architects, the “Leanest” option is not always obvious.

“Grandad always said, ‘Measure twice, cut once.’”

When clinicians are asked what they want in the new facility, most respond that they want “more.”  They want more space, more inventories and equipment, more computers in larger nursing stations…  This makes perfect sense if they will transfer the current batch and queue, broken processes they are working in today to the new facility. While adding more of these things helps to cover up the broken processes, they also increase the 8 Wastes.  For example, larger spaces increase travel distances (Motion); and large, centralized nursing stations create batching (Over-production) and interruptions (Confusion).

“Did they save money on storage areas so we could have this nice team room for group problem-solving and optimizing our internal processes?”

What’s needed is a framework based on Lean to bounce these decisions against and a coach with many years of experience applying Lean principles and tools.  But this will only work if the entire Sr. Leadership Team is bought into this new “common set of lenses.”   Without these common lenses, each leader on the team is left to view the design options through traditional lenses, and to do their best in bringing their staff’s wishes into the new design.  This inevitably leads to tradeoff thinking, as the leaders cannot find common ground, and therefore push their own agendas.

“How did they keep everyone focused on what was best for the patient and improving the total value stream before Lean Healthcare came along?  Didn’t Grandma call it Silo Thinking?”

Even if the leadership has made a commitment to make Lean the way they will do business in the future (which is required to operate in new Lean facility), this requires a bit of a “leap of faith,” so to speak.  Without years of experience in Lean, it is hard to SEE how much Waste will actually be eliminated with “Standardized Work” in “Standardized Facilities.” This is where the Lean coach comes in.

“Grandad kept us rolling on the floor with stories about how much they had to walk in the old building.  The formalin room was all the way on the opposite side of the department from pathology!  And all the plugs were down behind the head of the beds!”

At HPP, we call this process “Lean-led Design.” So, will staff working in your new facility for many years to come remember your team as the one who institutionalized Waste in it, or will they remember you as leaders who put a stake in the ground and said: “The Waste stops here.”

What questions will be asked about your new building?

This week’s blog was written by Dwayne Keller, Vice President of Healthcare Performance Partners (HPP). Dwayne has overseen the introduction and implementation of Lean Healthcare in various hospital and clinical systems throughout the USA. He coaches at all levels of Healthcare organizations, from CEO to front line staff to deliver improved outcomes via Lean. His deep understanding of Lean as a holistic process improvement “system,” and leadership guidance in connecting Lean implementation to each organization’s specific business case needs in a visual way, sets him apart in the industry. Dwayne has also been a speaker and lecturer at various Lean Enterprise conferences as well as a presenter at the Shingo Prize Conference. Dwayne began his career with DuPont as an Engineer and as an Industrial Engineer & Production Manager at Michelin Tire Corporation, he introduced Just-In-Time and Teamwork into two of their largest manufacturing operations. After earning his MBA, he spent three years in Michelin’s Marketing Department helping to transform it into a customer-focused research and data-driven organization. Dwayne joined Alcoa’s AFL Telecommunications Division as Plant Manager and later Director of Operations and drove implementation of the “Alcoa Business System” (ABS), which is its Lean Enterprise system, to meet business goals. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.