Guest Essays. Lessons Learned: A Systems Approach to Lean and Evidence-Based Design by Patricia Morrill and Kate Taege, Kahler Slater

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1 Guest Essays Lessons Learned: A Systems Approach to Lean and Evidence-Based Design by Patricia Morrill and Kate Taege, Kahler Slater At the highest level, healthcare leaders are faced with making key strategic decisions that will affect their organizations and their communities for generations to come. These decisions involve operational models, facility design and methods of care delivery that dramatically affect patients, as well as their families, staff and physicians. This article provides lessons learned in healthcare. The first section demonstrates what has been learned from using lean and Six Sigma methods for process improvement. The second and third sections focus on evidence-based design (EBD) for improving the built environment and combining these concepts into a systems approach to achieve optimal results. Lean and Six Sigma in healthcare Healthcare executives are increasingly turning to lean and Six Sigma to achieve rapid results in process improvement. Lean s focus is to reduce waste and improve cycle time, while Six Sigma focuses on reducing variation and eliminating error. Reported results from lean and Six Sigma projects are significant in reducing footsteps, shortening wait times, reducing inventory, increasing standardization, improving patient and staff satisfaction and lowering costs. Here are some insights into the lessons healthcare executives need to follow to prepare for these manufacturing-based quality programs. Lesson one: Be ready to provide direction and make timely decisions before, during and after lean and Six Sigma process improvement initiatives. Does the decisionmaking structure in your healthcare organization waste valuable time? Does the refrain, We ve been talking about that for years, and nothing ever happens sound familiar (see figure below)? Assuming the answer to these questions is a resounding yes, it is no wonder the same issues keep re-surfacing with complex structures in place for decision making in many healthcare organizations. As a solution, task forces are often created, but ultimately do not add value. The good news is that lean and Six Sigma tools help expose specific improvements needed, uncover root causes and facilitate solution options. To accommodate rapid improvement, however, sufficient planning is needed upfront to design a different structure for timely decision making. The executive serving as the sponsor or champion must empower the staff involved in lean and Six Sigma initiatives to carry out the improvement efforts. If that structure is not put in place, then the executive sponsor must stay more closely involved to assure direction and decision making are provided promptly.

2 During a workflow redesign effort for the two medical/surgical units at a community hospital, the executive sponsor participated in all four lean workshops. The first workflow priority was about the report process at shift change that was taking too long and creating overtime. Using lean and Six Sigma tools, the workflow redesign team identified measurable quality attributes important to the customer (known as critical to quality) and developed a value stream map to see the current process from beginning to end with cycle time and information flow. It soon became clear that the cause was the lack of a standardized report process, and after some research, a standard was developed. Nurses were then trained on the new process which included moving reports from a conference room to the bedside. A pilot study followed, which resulted in some adjustments before it was rolled out. The benefits not only included the stabilization of report duration, but also resulted in a 96% improvement in late report stops (reducing overtime caused by report). As an added benefit, duplicate work was eliminated. It was especially gratifying that both patient and staff satisfaction increased with this workflow redesign. Consistent executive participation and support gave the workflow redesign team the timely direction needed to be able to accomplish these significant results in just five months. Lesson two: Pay attention to improvement opportunities along the way. The lean and Six Sigma process journey itself is important. While we just recommended prompt decision making, charging ahead too quickly to fix a problem may lead to superficial solutions or send you down the wrong path ultimately solving the wrong problem. The quick-fix mentality must transition to a structured approach to uncover root causes where real transformations can begin to occur. Along the path to identifying the root cause, there are many improvement opportunities that surface as thoughts are shared. Be sure to capture these ideas, and honor and encourage creative thinking. It is this openness to innovative solutions that is needed to transform healthcare delivery.

3 We use an artichoke as an analogy to represent this concept: the outer petals may get discarded in a rush to get to the heart. In a lean process improvement effort for a hospital that focused on reducing patient wait times and walking distances related to registration, scheduling and admitting functions, the executive sponsor addressed the lean team at the kick-off session and voiced her nervousness. She was unsure where this initiative would lead, but she was excited to get started. During the next session, the multidisciplinary lean team developed a value stream map that exposed nonvalue-added activities and also helped the team realize the vast amount of back-of-house functions that occur in front of patients. One comment sparked another, and it was not long before the group was able to identify the need to separate back-of-house functions from front-of-house functions in the new facility design. This allows staff to focus on preregistering and scheduling future appointments in a back-of-house environment, with greeting and check-in occurring in front-of-house environments that focus on patient flow for the day. Extensive patient volumes data collection and analysis helped in developing a new work model for this organization. Evidence-based design Environmental design research in healthcare settings has increased significantly throughout the last several decades as healthcare clients are requesting architects and interior designers to incorporate EBD in their projects. The Center for Health Design defines EBD as The process of basing decisions about the built environment on credible research to achieve the best possible outcomes. 1 Designing a healing environment involves much more than just a facility. Lesson three: Train staff in cultural change just as they are trained in new technologies and facilities. A study of an inpatient unit s sound environment was conducted by observing sound sources and by measuring decibel levels. The intent was to develop a systematic EBD strategy for sound control for a hospital s new inpatient units. The findings indicated that human behavior and interactions were the greatest categorical source of sound on the unit, for example, overhead paging, staff s verbal conversations, whistling and key jingling. These are all noises that can be controlled. It takes a trained staff and adopted policies for a quiet culture, coupled with built environment changes, to achieve successful outcomes. Lesson four: Use a project vision as the guide for evaluating options and documenting decisions made. Many project visions are created, put in a binder and rarely touched again. The Evidence-Based Design Accreditation and Certification study guides

4 explain, The vision articulates the intentions and direction for the project and the EBD goals and objectives, which is the first step in the evidence-based design process. 2 Assigning a vision keeper 3 and conducting periodic vision checks keeps the healthcare executives and the design team members focused on the original intent. Vision checks gauge whether and how a project vision is reflected in the design and can assist the healthcare organization in identifying additional operational planning needs to achieve successful outcomes in the changed environment. A systems approach to lean, EBD By using an integrated approach with EBD and lean Six Sigma rather than treating them as completely independent initiatives you can obtain a clear understanding of your options and make challenging decisions that achieve patient centeredness and operational efficiency. Essentially, you will create a win-win environment. Changing an organization s operational processes and its physical environment to create a safe healthcare experience often involves a change in culture as well. By integrating culture with work process (lean Six Sigma) and facility design (EBD), the experience of healthcare delivery can be significantly improved. Lesson five: Empowering people is the very thing that makes quality and facility improvements more successful and more likely to be sustained. The definition of empowerment is To equip or supply with an ability. An empowerment culture promotes relying on the organization s most important attribute: the brainpower of its staff. 4 Engaging staff in endeavors to improve the healthcare environment experience cultivates the organization s transformation. But it takes a culture that promotes creative thinking and empowers people with tools to make a truly healing environment. References 1. Debra J. Levin, Defining Evidence-based Design, Healthcare Design, August 2008, p The Center for Health Design, EDAC Study Guide 2: Building the Evidence Base: Understanding Research in Healthcare Design, 2009, p The Center for Health Design, EDAC Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process, 2009, p Institute for Healthcare Improvement (IHI), Going Lean in Health Care, IHI Innovation Series white paper, 2005.

5 Patricia Morrill leads Kahler Slater s lean Six Sigma process improvement team and works with clients to improve efficiencies by analyzing flows and redesigning processes. Morrill has more than 20 years of healthcare experience, Six Sigma Green Belt and lean healthcare Certifications and is accredited in evidence-based design (EBD). Kate Taege, master of architecture and design researcher at Kahler Slater, is accredited in EBD and Leadership in Energy and Environmental Design. Taege has her Six Sigma Yellow Belt certification. Kahler Slater has a global reputation for designing environments and the experiences that happen in those environments. One of the firm s key areas of expertise is healthcare, where Kahler Slater is working to lead the industry in Designing Healing Experiences TM. The company s interdisciplinary approach includes architecture, interior design, planning, vision and brand development, environmental and behavioral research, multi-media design and marketing services.