Lean Design and the Future of HC

Posted on December 17, 2010

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David Chambers, Strategic Facility Planner for Sutter Health, presented an excellent lean design seminar at the Healthcare Design Conference (HDC.10) last month. Lean has finally become an in topic; in other words, it is a mainstream discussion item as evidenced by the standing room only crowd. The popularity of this particular talk was a testiment to the quality of the speaker, but also an indictment of how long it takes an idea to finally take hold and get more than a few people talking about it, let alone adopting it as general practice; lean is hardly a new concept. But I digress.

In past posts I helped interpret lean into the design realm and offered a resource for those interested in learning more about how lean translates to the construction industry. Mr. Chambers’ presentation explained how lean maps to healthcare.

To know lean is to understand it as an ideal concept, where everything in a process is perfectly efficient and thus no waste exists. Process waste, or muda as coined by the Japanese, is the target; the more it is eliminated, the leaner a process gets. Muda comes in eight (originally seven) types in healthcare:

  • overproduction
  • waiting
  • transportation
  • complexity
  • inventory
  • motion
  • defects
  • underutilized staff* (not an original TPS waste)

For those trying to apply this to their own clinic or hospital, the goal is to eliminate all of the above. Chambers defined waste in healthcare as “everything up to the patient getting healed”.  Waste is also anything that does not add value, but not all waste can be eliminated. This is the Catch-22.

Chambers’ lead into this list was quite interesting. He noted lean is a concept and a culture. Chambers discussed how lean as we know it from the Toyota Production System (TPS) was really an adaptation from Henry Ford’s innovatively efficient assembly line. Chambers explained the basic foci in healthcare as patient, value and time. To maximize the relationships between these three items, a facility should map out flows (every pathway during which anything happens) and execute mock-ups—something Sutter takes very seriously.

As Chambers explained some of the developments he has used in facilities, he challenged the HCD.10 audience for what I felt was the only time during the conference.  For me this was a powerful moment. He said as designers we are after “revolution, not evolution”. Compared to status quo healthcare delivery in 90% of America’s hospitals, lean is that exotic—a complete revolution. And designers should always be pushing owners out of their comfort zones when it provides the betterment of all.

One of Chambers’ noted implementations was a change from “cellular care delivery” to an environment where teams create outcomes, not individuals or departments; healthcare is and needs to be more collaborative. Chambers also called for a “removal of clinical technology from architecture”. To him, this meant de-coupling the expensive and quickly outdated technology from a hospital’s physical infrastructure. For example, the headwall connections should not be in a wall but in the bed, with the ability to wirelessly broadcast data. By eliminating air, vacuum, oxygen, etc. from the headwall, construction costs go down and inefficient motion is eliminated from processes—a lean double-dip benefit.

General items Chambers recommended to watch in facilities were excessive handoffs, starts and queues versus service provided, and the notion that randomness creates unpredictability, both of which are the bane of lean. Anything random has no repeatable process and thus no efficient way of execution. Finally, in a nod to retail healthcare, Chambers noted the future of hospitals should be “smaller and more mobile”, not large and monolithic institutions.

From these notes, I think it is easy to see how the fundamentals of lean process design dovetail well with healthcare delivery. To echo this sentiment, Clay Christensen has a telling diagram in his book The Innovator’s Prescription that elucidates how inefficient the processes that govern healthcare delivery are. It will take courage from both designers and administrators to overhaul entire engrained bodies of knowledge and standard operating procedures, respectively, to get lean to work, but it is a necessary revolution.

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Posted in: Lean Design