Lean by Design

The new Patient Protection and Affordable Care Act demands something wholly different: competition based on quality, safety, and effectiveness of care, not quantity. That's where Lean design comes in.

This coming June marks the one year anniversary of the Supreme Court ruling to uphold the Patient Protection and Affordable Care Act. The Act’s focus on cost curtailment means that providers can no longer afford to approach care as a disconnected batch of siloed services. Care models are rapidly evolving into a continuum of care measured by patient outcomes. Architects cannot keep building more and adding rooms to solve constraints. Instead they must solve the root cause of the constraint using a “Lean” approach that addresses the process and flow of work.

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 its ability to realize significant improvements in safety, quality, lead time, and financials.

In the traditional building design process, architects solve problems by multiplying growth factors by square footage when addressing increased patient volumes, service extensions, or changes to clinical practice. They sometimes look at process flows, but often default to what clients want based on their current "batch processes"—essentially providing more of the same. Unfortunately, in this approach, the original process wastes are never identified or fixed leading to the same problems as before, only on a larger scale.

When architects use Lean methodologies to tackle questions of growth or change, the people who do the work in the space participate in the design process and are challenged to examine wastes in their current work flows from a new perspective. The objectives shift so that the building (whether renovated or new) is looked at as a tool for better patient outcomes and experience, staff satisfaction, safety and flow.

In Lean design, both client and architect engage in a different mindset. The architect no longer rushes to show the client several layout options before understanding the process flows. Clients commit staff and time up front to observe and map the patient journey. Multidisciplinary teams (which also including patients and families) then work together to develop and test the best work flows that encompass the entire spectrum of care: patient, family, providers, staff, equipment, information, supplies, medication, and instruments. Multiple solutions are tested until the team creates improvements to the patient’s journey and new process flows that remove waste. In this process the architect acts as a facilitator for improvement opportunities. As architects translate the team’s new work process and patient experience improvements into physical space, there are clear performance goals in sight.

NBBJ has been integrating Lean practices into design services since 2001. Our journey began when we partnered with Boeing to apply Toyota Product System (TPS) manufacturing principles to the design of an airplane assembly facility. Boeing's use of Lean caught the attention of Virginia Mason Medical Center and NBBJ joined their Lean "3P" process on several groundbreaking projects. We've partnered with other leaders in the Lean healthcare movement, including Seattle Children's Hospital and Alaska Native Medical Center. Our own healthcare practice uses Hoshin Kanri management and other Lean processes to eliminate waste from our design process. In 2011, NBBJ launched a Lean certification program for design professionals.