Lean Design in Healthcare / Healthcare Facility Planning

Husaini Sadikot

Lean production can be described as a group of highly efficient manufacturing techniques developed (mainly by large Japanese companies like Toyota) in the 1980s and early 1990s. Lean production was seen as the third step in a historical progression, which took industry from the age of craftsman through the methods of mass production, and into an era that combined the best of both. Better craftsmen or types of doctors give better quality and variety of types of products, while mass manufacture methods if applied to medicine can give more, faster and cheaper and more similar products. Mass manufacture methods if applied to medical problems may give a less personal medical service.

Lean manufacturing (lean enterprise, lean production or just lean) is a production process that considers the expenditure of resources for any goal other than creation of value (best quality, highest quantity, and best and most suitable type of product made in the least time and least possible cost) for the end customer to be wasteful, and thus a target for elimination. Working from the perspective of the customer who consumes a product or service, value is defined as any service, product action or process that a customer would be willing to pay certain levels of price,(not too much, not too little)depending on the service, action, product or process.

Hospitals are designed and organized by department function (functional layout), that is each department specializes in certain medical or technical functions. This leads to:

• isolated departments (like laboratories, radiology, ORs and ICUs etc.) each department behaves like a functional silo

• A functional silo is an individual medical area function department that tends to act as a stand-alone function, often formulating its own strategies and work plans. This expression is used when describing a departmental organization whose functions tend to be less communicative and less collaborative with other departments. A functional silo can also be described as a functional group or department within an organization that acts as a lone silo or island in its lack of interaction with other groups or departments and in not sharing its internal data or processes.

• Each department is a single function area where similar equipment is located. The entire department including most trained skilled staff specializes in similar processes.

• Each department seeks to maximize their efficiency and utilization.

Well known disadvantages of a functional organization include:

• long patient throughput for treatment in one department or long movement between departments times.

• poor overall process control and quality of care
• complex patient flow routes as patients go from department to department which may be located far from each other all over the hospital

• Absence of fluid patient flows. Fluid patient flows may be achieved by quick travel from department to department and the patient is quickly treated in each department.

• long transfer distances involving many multi-department visits increasing the time for overall treatment

• Complicated scheduling. It may take a long time or long uncertain waiting times to get an appointment in certain busy departments, leading to problems making appointments or a timetable for patient treatment. Departments may be busy for many reasons including understaffing, not enough or easily accessed equipment, Too many patients having the particular medical problem or illness the department specializes in and long times for treatment for the medical problem the department specializes in.

What does it mean to be a product focused hospital?

• The real product of a hospital is a treated patient ready to go home.
• All staff and equipment used in the treatment of a “family of illnesses” would work in one place as a multi-professional group.

The larger the overall hospital, the more likely it is that departments due to their large size to deal with more patients, will be more divided by medical functions, with more specialized departments. To save time and be more efficient, inter-departmental transfers of patients should be minimized, with as much being done in one big multi-department set up as possible.

Proven Benefits of a Lean design product or cellular organization:

Fewer interdepartmental patient transfers-quick throughput times-less patient travel-lower transfer delays. Such an organization could be patient rooms or wards, or emergency departments where patients with a large range of medical problems have to be quickly prioritized by a triage nurse according to whether or not they need immediate treatment and the type of treatment they need, and intensive care units where doctors leave their surgeries and visit patients rather than patients being moved to different specialized departments where specialist doctors and specialized equipment are. Not many specialized hospital equipment can be brought to patient wards, so a certain amount of patients going to different departments where large equipment is used would be involved. General Practitioner doctors cover and treat almost any medical problem and so may be seen as multi-medical specialty departments. It should, however, be noted that for tests or specialized medical treatment or scans, the General Practitioner would refer or direct the patient to other departments, and locations.

Reception areas usually have to be near entrances so that people can register and give their details and get information about where to go, but receptions should also be as central to all departments as possible. It would be possible to have more than one receptionist to direct, take and give information and check-in patients in large multi-department organizations like hospitals. Further, an analysis of patient departmental transfers to find which departments patients are most likely to be transferred between could be done based on hospital records. Then the departments’ patients are most likely to be transferred between can be made next to or close to each other. Some services in hospitals departments like often done blood tests analysis and X -rays would have to be in or close to other departments like bone fracture clinics, emergency, and intensive care units. In some cases, more rooms or larger rooms may have to be used for often done functions like blood analysis and X-rays.

As far as area is concerned, there is the catchment area from which the hospital gets most of its patients, and the area or space within the hospital allocated to the different medical specialties, arranged in area, shape, and configurations for most quick and easy transfer of patients between departments of certain medical specialties. Departments, where patients wait longer or longest, can be made bigger, and have more staff and more equipment, to reduce waiting periods.

To save money, as far as possible hospitals or clinics can be built in existing renovated buildings. If the existing buildings are in very bad condition, it may be cheaper to demolish the building and build new buildings on the empty land, custom made for the type of hospital required.

Errors are a waste and can be prevented by having 2 or more independent experts examine the same patient or illness, and by comparison of symptoms, case history etc. with previous similar cases. Correct diagnosis can be increased and errors decreased by having two or more different doctors, experts or specialists, giving the patients diagnosis. He doctors, experts or specialists should be independent and not know the other doctors etc. are working on the same case. Other ways errors can be decreased is by looking and comparing at as many cases histories as possible, where the exact and total history of symptoms of the current undiagnosed patient are as similar to the history of symptoms, including parts of the body or mind the symptoms appear inland how often the symptoms appear of the case histories. The diagnosis that was reached in the case histories from the same symptoms as the unknown, undiagnosed patient has can then be made for the unknown patient in question. Computers could be used for matching correctly diagnosed, correctly treated and recovered patients in as many similar case symptom histories as possible, to the exact and total symptoms of the unknown, undiagnosed current patient. It would have to be determined whether more time spent

Getting 2 or more independent opinions would save more time than when 1 opinion is obtained and there are more errors. Errors in the treatment of patients can raise the cost and time taken for each patient and errors should be reduced to a minimum, possibly by more scans and tests on the patient at least possible time and cost. Medical errors can include defective surgery, defective transfusions and defective medication administration, types and doses.

Administrative hospital errors can be avoided by a more efficient administration for things like bills and pay checks. As far as design and staff layout and organization is concerned designs of existing most efficient hospitals and most efficient administration can be researched. The best and most efficient hospital arrangement of departments, staff, and patients can then be copied in design. Errors can be prevented by the attitude, training, and experience of experts and other staff, which can be helped by the design layout and environment of staff and patients. Errors can be prevented by designed working layout and environment being suitable to prevent errors, such as the arrangement of staff and working furniture in rooms or partitions or cubicles. Environments like color may help like having certain more suitable plants like flowers, views or water or plant views.

Wards where patients rest should be furthest from noise like traffic noise as possible like furthest from roads and on top or upper floors of a hospital particularly in city areas. Seven wastes include too much transportation, waiting of staff i.e. staff not doing anything, over-production like too much time being spent on each patient, defects such as the wrong diagnosis of illnesses or errors, over processing and more inventory like food, equipment, and medications than is necessary. It should, however, be noted that under inventory or too little inventory can also lead to delays and lost, unhappy, waiting patients, so too much inventory may be better than too little inventory.

In overproduction, more products may be left unsold due to more products made that demand for these products. Thus the cost of making extra unsold products, like labor, material and storage costs may not be recovered.

Right treatment and medication in the right amount at a right suitable time and place would also reduce errors. Design can help by getting patients to the right place as quickly as possible for example having receptionists sending patients to the right department, as near to a central receptionist as possible.

In healthcare facilities, areas of waste typically include overproduction, waiting, inefficient conveyance (such as transport, carriage, trolleys or vehicles), rework like misdiagnosis, excess inventory, unnecessary motion such as overlong walking distances for nurses, doctors and patients, excessive patient movement and transport, and correction or steps taken to remedy situations caused by wasteful practices like staff errors and wrong diagnosis of patients.

Design of a facility can support efficiency and can result in lower operating costs. Lean design identifies, locates and removes operational process waste. The aim of lean design is to do more with less equipment, cost, time, space, staff etc. The aim of lean design in for example a hospital setting is for the patient to visit the doctor, get a scan like MRI or an X-ray, and have it read, receive an accurate diagnosis and pick up medication from the pharmacy all in one visit in streamlined lean parameters.

If the X-ray or scan or other test facilities are far away from the doctor, multiple visits may be required before diagnosis and treatment and care can be given.

Generally in a multi-department, multi-stage process as in a hospital situation, there are certain steps in the admission and treatment of patients that can slow down the entire process. Such rate determining steps or stages can be speeded up and quickened, with the aim of speeding up the whole hospital process. For example in a hospital, waiting for a doctor to see you can slow down the whole the whole hospital treatment and care process. Therefore more equipment, more doctors, and nurses and more other staff capable of faster diagnosis and less error in diagnosis, would speed up the process. Wrong or error diagnosis can mean a patient is treated more than they would have been with better diagnosis. The better quality product of a hospital is a treated patient with relief from the pain and discomfort that most illnesses or injuries bring, able to as far as possible lead their usual life, in not too much or too little but just right to satisfy the customer time and cost.

Another factor that can slow down the hospital process is the lack of closeness of supply and equipment, from the department doing the tests or treating. Lack of close storage space and space for

Equipment etc. could be due to too small department’s space like too small rooms, or planning and design in a way that a particular department’s supply storage is too far away. Any empty space in a department could be used to create cupboards or other storage space for keeping most used and needed supplies.

Other things that can speed up the hospital process are the sharing and update of the patients’ details between departments, as the patient goes from department to department. Any excess time that the patient has to wait may be used for form filling and details updates. Such sharing of records prevents wasted time from repeated form filling of the same information, and questioning of patients in each stage or department of treatment. A reduction in paperwork means staff can spend more time on the treatment and care of the patient. More space would help but is not always the problem in delaying treatment and increased waiting times. A hospital where departments are planned around a centralized and other connected reception areas (such as at the entrance to assess and tell the patient where to go) can speed up the patients’ treatment and help in sharing of the patients’ treatment, records, and other treatments.

A balance between more staff to speed up the admission and treatment of patients, and efficiency of each staff member, and costs of employing more staff has to be reached. Often slow or rate determining steps can occur in the treatment of patients in a hospital or other institution. Such rate determining steps can determine the rate at which overall patients are treated in a departmental hospital. Therefore the best, quickest and least error making staff can be put in such rate determining departments, to speed up the whole process. Basically, the whole inter-departmental patient experience is only as fast as the slowest step, in the slowest department or departments.

In hospitals, each department can be very big depending on the size of the hospital. The size of the hospital could depend on things like the area of land available to build the hospital, though to some extent smaller areas of land space can be overcome by having more floors or floors in the hospital buildings. The size of the hospital could also be determined by the number of patients or potential patients that exist in the area the hospital serves. For densely populated areas like city areas there would be more potential patients and so more and larger hospitals per unit area may be required. Another alternative when more hospitals are required is rather than have very big, difficult to manage hospitals with large departmental buildings and so more time wasted traveling from department building to other department buildings for staff and patients, is to have many smaller hospitals per unit area. Smaller hospitals can have smaller more personal service departments, and that might make less time spent organizing and transporting patients and staff from department to department. Therefore it may be that all the various buildings where possible, may have to be located in certain configurations like rectangles, as close to each other as possible, to speed up patient treatment. Within each department, the various equipment and staff may also have to be arranged in configurations that make the transfer of patients within a department as fast as possible. One way the buildings can be arranged is to research which departments have patients transferred from and to the most often and to have such buildings or departments as close to each other as possible. Buildings or departments furthest away from each other could be departments to and from which staff and patients are transferred least often.

A patient treated and ready to go home and able as far as possible to lead a normal life with least medical treatment is the product of a hospital. Over-production of a hospital could be over treating each patient and keeping each patient in the hospital longer than is medically necessary or treating patients for illnesses they do not have. Such over-treatment of particular patients could mean less time for hospital staff to treat other patients. Treating patients for illnesses they do not have could be errors in diagnosing the cause of the patients’ illness discomfort. Over-production in other industries is more production than the demand there is for the particular product, leaving products unsold and therefore wasted. Therefore the total cost of the overproduction may not be recovered. Hospitals basically provide a service. Over-treated patients would still pay for the overtreatment, though too large bills for the patient to pay may discourage patients from coming to the same hospital if choices of other hospitals are available. Overproduction in medicine could be treatments that the patients do not want, to overcome their illness symptoms discomfort.

Sending patients home earlier than necessary to treat other patients and create empty rooms and beds for other patients, could be underproduction. Underproduction is also a problem since it means some customers or service users are left without products or full treatment, which may put them off

And discourage them from dealing with the providers of the product and make them go elsewhere. The objective of lean design in hospitals is to design a high-quality service that could be delivered at the required patient demand volume, with the correct treatment timing, for the lowest possible cost. In medicine, the 7 lean flows that most efficiently (highest number of patients treated correctly by fewest number of staff in fastest timing) optimize the flow of patients, include the unhindered and fast flow of clinicians like doctors, nurses and technicians, the flow of medications, supplies, equipment, information and process engineering. Such flows would be fastest with less waiting time and most efficient if things like medications, other supplies and staff like doctors, nurses and technicians were immediately available when needed by patients.

Architects can affect lean design by making space just the right size to accommodate enough staff and equipment and to meet patient demand.

There are seven types of waste incentivized in the lean production system including:

• Overproduction-production more than and not associated with demand. In medicine, this could be an excessive treatment that does not meet patient demand, such as treatment that does not affect or improve the patients’ condition. Overproduction could also be a treatment that does not have value that is the treatment of patients that are not fully or partly paid for.

• Transportation-movement of products unrelated to production. In medicine, this could be the movement of patients between departments, unrelated to the effective treatment of the patient.

• Waiting time or wasted waiting time between value-added production steps. In hospitals, such waste could be long waiting times for effective treatment.

• Motion-unnecessary or excessive movement of equipment, staff, and patients, like long distances traveled by staff for supplies, use of equipment which could affect the time for effective treatment to be given. (Longer distances traveled for more types of supply and equipment, would increase the time taken for treatment procedures).Patients traveling long distances for different types of tests, scans and treatment could also increase overall time. Traveling is a type of motion.

• Inventory-too many unnecessary, unneeded components on hand. Such components include extra equipment, more supplies stored in a given space than is required for the treatment tasks done in that space, resulting in space taken up that could be used for a more relevant type of equipment and supplies. Too many hospital beds in large ward rooms possibly resulting in empty unused but prepared serviced beds could also be seen as too much inventory.

• Over processing-unnecessary or for whatever reason like to correct errors or lack of good judgment in diagnosis, repeated procedures or treatment.

• Defective products-time required for the detection and repair of defects. Since the product of a hospital is an improved by treatment patient, a defective patient could be a patient who has got worse or is not cured due to medical errors.

One of the more specific and focused lean tools is the 5S method, which is a systematic approach to organize and manage a specific workspace or workflow to improve efficiency and reduce waste. The

5S concepts include:

• Sorting-the removal of all unnecessary items from the workspace by sorting out and keeping needed items close, where they can be quickly accessed and found and removing unneeded items, to places like departments where they may be more often needed.

• Simplify-the orderly arrangement of items and spaces required for the process or procedures or treatment. If items and spaces such as departments or rooms in a department or items in a room are arranged in an orderly arrangement such as the arrangement in the order they are needed for a particular product or procedure, the overall treatment procedure may be simplified and done more quickly.

• Sweep-daily systematic efforts to keep work environment clean and orderly, such as the removal of waste which may take up needed space.

• Standardize-performing a task in the same most efficient way (most patients treated correctly by least number and least senior but more in number staff, in the least time and space, with the same most efficient programmed steps)regardless of who is performing the work.

• Self discipline-sustaining practices and procedures developed in the preceding steps.
• The design of ward layouts and nurses stations to reduce staff and patient walking and staff and patient fatigue, increase patient care time, and support staff activities such as medication supply, communication, charting and respite from stress.

The lean philosophy has begun to streamline processes in hospitals where it is useful in designing buildings where those processes take place.

Process waste in hospitals can include:

• Nurses and other staff running long distances for supplies. Planning can remove such time waste and tiring processes by having enough space for both nurse’s patients and relevant storage as close as possible to one another.

• Rework, re-admissions, infections, medication errors. How architectural lean design such duplicating or repeat of the same work is not clear. Some ways lean design can help in hospitals are designs that enable specialists, senior and junior doctors to work closely, so senior experienced doctors can cause fewer errors to be made by more easy design led access to junior doctors. Further design or planning of spaces so that two or more specialists or senior doctors (to reduce errors made when only one doctor makes a diagnosis) can give an independent diagnosis of a patient’s condition, as soon as possible.

There are some indications above about how designers and planners can plan hospital spaces to support lean design. However, an architect may plan the whole building or buildings spaces including the size and number of rooms on each floor of the building, but may not necessarily have a say in planning what departments and staff the rooms are used for. Further things like location and number of reception centers and signage of where departments are and what to do, which could help efficiency may not necessarily be something the architect does, but may be done by hospital management.

Hospitals are more about medical service delivery than the production of things in a conveyor belt type production system. To a large extent better more value efficient hospitals can be designed and made by looking at and copying existing, tried and tested good efficient hospitals, and therefore how similar hospitals can be made by design.

Paying for a hospital service means that errors in patient diagnosis that may result in more overall patient treatment time will also be paid for. In service orientated payment systems, overproduction like longer service due to errors would still be paid for by patients or customers. Overproduction in conveyor belt type manufacturing systems, where there is too much production and too little demand, would mean losses due to unsold products.

Treating patients in a multi-department type conveyor belt type treatment system would be more difficult in hospitals. In large hospitals serving an area of high population per unit area, and providing more medical services or medical function due to its size, large departments are often necessary, due to higher numbers of staff, equipment, and patients per department. Smaller hospitals or organizations, in general, may give more personal service, with senior and junior staff having more personal contact with patients. It would have to be determined from experience or by comparison and looking at other by evidence (such as statistics showing well-managed hospitals)smaller or larger organizations whether such organizations treat more patients in a given time, given area, least number of busy staff used and least cost to patients and least cost and most profits to the organizations. Lean design value to the patient or customer would be most successful treatment in fastest time with least total charges to the patient, compared to other similar businesses, organizations or hospitals. Lean design value for the service or product giver (such as hospitals) is most service provided at least total cost and most profits, which would be helped by successful services provided in the least designed building area, the least total time taken and least busy staff time taken.

It is better to have overproduction than under production. In hospitals, overproduction can also be a

Product or service provided but the customer or patient does not pay for, but takes up staff and equipment time and space. In effect, overproduction in a hospital is any service given, that the patient does not pay for. Underproduction can be seen as a service patients are willing to pay for, but cannot be provided by the hospital. In medicine, overproduction is over-servicing. Underproduction is service patients are willing to pay for, but cannot be provided by hospitals.

Just as in manufacture overproduction is making of more products that are more product supply than there is demand for, overproduction in hospitals could be more supply of medical services than there is demand for in the area or catchment the hospital serves that gets its patients from. Such medical services could then be reduced in amount I.e. allocated less staff, money, and space, until and unless demand for the overproduction changes to underproduction. Overproduction or over-servicing in hospitals could be too much staff, equipment and supplies (inventory) like medicines than there is demand for. Underproduction or under-servicing could be too little staff, equipment, supplies and allocated space to meet patient demand resulting in longer treatment time and longer queues. On the whole, it is better to have too much staff, equipment, supplies and allocated space so that everyone can get treated quickly when necessary. More patients correctly treated, in the least time(e.g. by treating as many waiting patients at the same time by having enough space, staff, equipment, and supplies), and treated by least staff and least senior staff means more profits in the least time taken.

Too much staff, equipment, and space can be as much of a problem, with staff and equipment doing nothing for longer times, as too little staff, equipment and space, which can increase patient waiting times and create queues and possibly turn some patients or customers away, thus losing patience and income.

Supply and demand of hospital services can also determine how many, and how long, and what type (what illness specialties) of hospitals are required, in the particular area and time that creates the treatment demand which the hospital serves and supplies.

Areas or suburbs where hospitals are built may be determined by how many other hospitals with similar medical services are near or in the area where the hospital is to be built. It is best to build a hospital or business, in or near an area where there are few or no similar service/product offering hospitals or businesses. Some specialty services provided by few hospitals may attract by treatment necessity, patients from distant areas from the hospital. Treating patients like making products on a conveyor belt type production system, may not be possible due to things like long treatment times in each or certain departments the patient goes to.

Rooms or buildings that make up a hospital complex, can be designed or allocated to different departments depending on how much space is required for staff, furniture like beds, equipment like scanning machines, patients waiting and staying in departments and storage of supplies. Since there are many departments and department functions, allocating rooms or buildings of different size to each department can be difficult since if too little space is allocated, patients may have to wait longer due to not enough space for more available staff and equipment to treat more patients simultaneously, rather than one at a time, to speed things up. Giving too much space to a department is better than too little space, with as many departments as close together for quicker patient transfer and throughput, as possible. In city type areas where land may be difficult to find and costly due to high demand for land from an increasing population per unit area of land, combined with low supply of land due to land already being used for a large variety of things such as housing, shops, businesses and factories, the most efficient use of land to accommodate a large hospital would be to build multi-storey hospitals.

The busiest and therefore possibly slowest hospital departments, with patients waiting longest for treatment, should be given the most space, equipment, and staff. Such departments may be determined by looking at similar hospitals in near or similar locations(different locations may have different health problems or illnesses predominantly, and so hospitals in different locations may have departments specializing in the predominant illnesses in the location, as the busiest departments),or looking at historical records of hospitals in near or similar locations(similar locations could mean predominance of certain types of people like aged people or different races who could have a predominance of certain illnesses).

Departments that have the most transfers of patients between them (which can also be determined by

looking at records of similar hospitals in similar locations as the hospital to be managed and/or built) should be placed as close to each other as possible) even if the same department has to be in more than one location e.g. the X- ray or other scanning equipment may be required often in the emergency and bone fracture clinics and other departments.

It was stated above that lean design could be achieved by having more hospital departments combined together to achieve more patient throughput or smoother flow between departments. The larger the hospital, the more likely it would be that each department has more patients to treat, and the more likely it would be that the hospital is divided into bigger, more separate, large less personal, medical specialty departments, with resulting less communication and longer patient flow between departments. Smaller hospitals could have more multi-department or joint department management to improve the speed of patient flow between departments.

Since lean design concentrates on most value to the customer by for example reducing wastage and errors, it would have to be determined if in a particular type of area and population (in different areas there may be more males or females, more children or young or old people, more prevalence of certain diseases or illnesses in certain areas) larger or smaller hospitals are preferred by patients. It would also have to be determined if larger or smaller hospitals result in less charge to the patient or customer for a particular type of medical service. It would also have to be determined if larger or smaller hospitals give more profit per patient, and which type of hospitals have more profits and less operating costs per patient, for different medical specialty services,

Equipment, space, time and staff that is not being used, that the patient pays charges for its use, is wasted, space, time staff and equipment to the organization, and the cost of buying such idle equipment would then take longer to be recovered. It may be best to have them as much different equipment and different medical specialty staff arranged in buildings or rooms as close to each other as possible, for the quickest and easiest movement of patients in the hospital.

If there are some departments where the staff is consistently not doing anything, they can be moved, if their specialty is suitable, to departments where staff is consistently busy. The aim of the lean design is to give value to the customer. Overtreatment the patient pays for, wrong diagnosis or under treatment is not necessarily giving value to the customer. For hospital patients might consider they have received value if they feel better or are cured.

To manage large organizations, the larger the organization the more the organization would be split into big less connected departments. Smaller organizations could have more multi-department or joint- departmental management to improve the faster flow of customers between departments. Since lean design is about giving value to the customer. It would have to be determined if larger or smaller hospitals are preferred by the patient. It would also have to be determined if larger or smaller hospitals result in less charge to the customer or patient, and whether the operators of the hospital get more or less profit per patient.
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This article is written by my cousin, Husain Sadikot, a guest blogger. He has a PhD in Chemistry.