Webinar | Lean Building Design in Health Care

Q&A

Chris Backous answers questions from participants:

Q: How much observation is needed before a 3P?

A: We have standard work for the six-week planning period that leads up to the 3P workshop week. As part of this planning period, we make observations of the current-state process flows and space challenges. Data collection is most intense during the start of the six-week planning cycle and then typically tapers off by the final week leading up to the 3P. We encourage those who are observing to allocate at least 50 percent of their time to do so. As part of the observation process, current state value stream maps are developed, along with demand data, opportunity data, market demographics, and patient and staff experience.

Q: What are the best metrics to collect during a facility observation?

A: The metrics to draw from the observation period are those that best describe and reflect the current-state process flow and layout challenges, including: current-state lead time, or the time for the process from beginning to end, cycle time for each operator providing care, process defects, and all wastes that cause burden of work for staff and challenges for patients.

Q: Does Virginia Mason Institute offer onsite lean design consultation services?

A: Yes! Virginia Mason Institute provides Lean Facility Design seminars, as well as, 3P facilitation. Each year we provide several opportunities for individuals or small groups to come to our training headquarters to learn and see firsthand how we integrate lean thinking into facility design, as well as, provide examples through guided tours of Virginia Mason lean facilities. Organizations with specific projects in mind benefit from a Lean Facility Design seminar that has been customized just for them.

Q: How do you determine if windows are in onstage or offstage areas?

A: Many of the clinics we have designed using our 3P methodology place the staff work areas, or offstage space, along the windows because of the time staff spend at work is much greater compared to the amount of time a patient spends in the clinic. In the case of our Cancer Care Outpatient Infusion Center, however, we gave the windows and the view to our patients, who are often with us for up to eight hours of infusion. One thing that we are careful to do when we provide windows to patients is to make sure that their privacy is protected with appropriate screening materials.

Q: How do you recruit patients to participate on a design team?

A: We recruit patients by reaching out to them. Some patients have expressed their desire to be more connected with Virginia Mason’s work to improve care and the patient experience. We formed the Patient-Family Partners program so that we could better match their interests to our needs for their involvement. When we work with clients who have requested 3P facilitation, we encourage patient outreach and engagement as well as workshop participation as part of the planning process. We work within the patient-engagement structure that already exists within our clients’ organizations. When clients lack formal patient-engagement activities and programs, we share our best practices for reaching out to patients during the preparation and planning process.

Q: Liberal use of interstitial spaces significantly drives up the upfront capital and operating expense as reflected in your net-to-gross ratio. What is Virginia Mason’s benchmark for expected patient revenue per square foot or ratio of square foot per patient room?

A: Virginia Mason uses all of the same metrics for facility development and performance. In addition to these metrics, we also look to metrics that reflect our desire to improve our use of all spaces. We look at flexibility, sustainability and adaptability. The interstitial spaces are a side benefit of connecting a building built in the 2000s and its associated ceiling height requirements with a facility built in the early 1960s, when ceiling height requirements were lower. We looked for a way to connect every other floor of the new Jones Pavilion tower to the existing Central Pavilion tower so that we could take advantage of the horizontal adjacency between the two buildings. As we worked on the matching of the every-other-floor concept, the additional ceiling height spaces provided this opportunity for the interstitial spaces.

Q: How did you enlist the support of your facilities services groups to help with the creation of the mockups in the surgical areas?

A: Virginia Mason’s Department of Design, Renovation and Construction (DRC) is an equal partner on all facility-related projects along with our executive leaders and our Kaizen Promotion Office. Leaders in the DRC are expected to become certified in the Virginia Mason Production System (VMPS) and lead improvement, just like all members of leadership at Virginia Mason. The lean process improvements they have made using VMPS has touched the capital-planning cycle, construction safety, and the way they assign, plan and manage all Virginia Mason facility-related projects. We have realized significant gains in quality, delivery, service and cost as a result of bringing lean thinking into the work.

Q: Assuming physicians are engaged in your planning effort, how has lean design assisted them in meeting their RVU benchmark?

A: Each lean facility design 3P workshop requires metrics for success. When we bring lean thinking into outpatient clinic design, quite often the throughput and productivity gain metrics are declared. Our work on the design of both the future-state process and facility is not done until we can demonstrate that these designs can deliver their desired performance for organizational success.

Q: Is there evidence-based literature at present that suggests 3P works in lean design?

A: We have measured improvements to service, delivery and financial performance with each lean facility design effort by setting clear performance criteria in the preparation and planning process of 3P facilitation events we lead. Lean, evidence-based design is a growing trend within the facility design industry. The key to success lies in the ability to declare measurable targets and the ability to achieve these targets. Our experience at Virginia Mason Institute has shown that successful implementation of new process flows contributes greatly to the performance of any facility designed using lean methods.

Q: Does Virginia Mason Institute offer training that is not onsite in Seattle?

A: Yes. We offer Foundations of Lean in Health Care as well as Creating Flow in the Ambulatory Setting at our regional training sessions held several times per year across the United States,
as well as, onsite in our Seattle training headquarters.

Q: How can you optimize the workflow without redoing 5S, a spaghetti diagram, etc.?

A: 5S (sort, simplify, sweep, standardize and self-discipline) and mapping the flow using tools such as standard work sheets (spaghetti diagrams) are not static activities. Waste is eliminated and we achieve more reliable flow and quality in our processes when we use 5S. 5S allows us to better organize our workspaces and workflows, and it becomes easier to see the next improvement opportunity, and the next, and so on. Kaizen is continuous improvement, where one effort builds upon the previous effort and highlights where to go next with lean improvement.

Q: How do you determine who should be involved with an RPIW or other improvement work?

A: RPIWs (rapid process improvement workshops), kaizen events, 3P workshops and everyday lean activities should be done by the people who do the work. They are the best experts to improve the work. By understanding the current-state flow in the form of direct observation and value stream development, it becomes clear who should participate in the improvement work. The general rule is that if the work they do is represented in the current-state value stream, then they should be included in the improvement activity.

Q: How do you determine if a process has waste? What if the waste is needed? How do you bust the assumption that “this has to be the way”?

A: We believe in the importance of “go see, ask why, show respect,” which means that before any judgments or assumptions are made, we must go to the front line, see the actual work and document the opportunities as we see them. Waste, or “muda,” is anything that does not add value to the process and can take the form of motion, defects, time, overproduction, inventory, processing or transportation. Waste can either be Type 1 activities that add no value but must be done to meet regulatory requirements or Type 2 activities that contribute no value and must be eliminated. We also look at “muri,” which is the waste of unreasonableness, and “mura,” which is the waste of unevenness. In order to understand waste, you also must understand value. Our definition of value includes all of those activities that a patient is willing to pay for or those activities that can change the patient experience for the better.

Q: If you remove the waste from the waiting room, is it just shifted to another space?

A: We haven’t removed or eliminated waste if another team upstream or downstream inherits it. The key is to “trystorm” (brainstorming plus quick prototyping) the ideas that improve the process for all in the value stream.

Chris Backous, MHA, is a senior faculty member at Virginia Mason Institute. He leads improvement activities, workshops and training for health care leaders and providers worldwide. By embedding innovative methods into the lean concepts he teaches, he works with clients to unlock the revolutionary thinking necessary to transform health care. In his 3P projects at client sites, he works with health care leaders, architects, medical planners and general contractors to design or redesign ambulatory surgery centers, emergency departments, inpatient and outpatient care environments, urgent care centers, labor and delivery facilities, cancer care facilities and patient safety programs. Prior to joining Virginia Mason Institute, Chris led the integration of lean methods into the design of Virginia Mason’s 350,000-square-foot hospital addition, the first environment of its kind to be built from the ground up using the Virginia Mason Production System. He also led numerous improvement events using lean tools and methods to improve health care processes. Chris is certified in the Virginia Mason Production System® and 3P (Production, Preparation, Process) facilitation.