Lean Healthcare Facility Design

November 18, 2008

James Nesbitt, MD, MMM
Project Manager, Department of Operational
Excellence
Providence Alaska Medical Center
Anchorage, Alaska, USA

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 Description of PAMC
• 365-bed acute and tertiary care hospital in
Anchorage, Alaska.
• 2,700 employees
• Over 500 physicians
• Operating Revenues of $511 M
• Operating Margin of 6.0% for 2007

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 Overall Need
A new bed tower designed to achieve
outcomes that best serve patient safety
and well being while eliminating waste
wherever possible

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 Be Proactive
“Design out the 7 wastes of healthcare in
advance, while the facility is still a concept
or lines on paper.”
– Charles Hagood, CEO, Healthcare
Performance Partners (HPP).

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 Why redesign work on
nursing units?
• Nurses spend 31-44% of their time in direct patient care activities
• Nurses experienced an average 8.4 work system failures per 8-hour
shift dealing with:
– Medications
– Orders
– Supplies
– Staffing
– Equipment
• Nurses spend 42 minutes of each 8-hour shift resolving operational
failures
• ….and we are experiencing a nursing shortage!!!

Anita L. Tucker and Steven J. Spear, Operational Failures and

Interruptions in Hospital Nursing, Health Research and
Educational Trust, 2006, pp. 1-20.
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 What are we trying to accomplish?

• Eliminate wasteful activities (hunting and gathering,

rework, workarounds, hassles, etc.) through process
redesign and physical space redesign
• Improve care processes so that nurses can spend more
time in direct care with patients
• Demonstrate that wasted time has been
reallocated to direct patient care activities (that
improve care and that meaningfully include the
patient and/or family members)
Rutherford, P, Value Added Care Process, IHI
presentation, Feb 2008

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 Patient-Centered Lean Design

Value Orientation and Cultural

Transformation:
– Define value from the patient’s perspective
• List patient likes, dislikes, and delights
• Collect patient stories
• Create a mind map of the varieties of patient
experiences
• Brainstorm ways for staff to work differently to
achieve patient delighters and avoid patient
dislikes
Spiering, K, FacilityManagement.com, October, 2008

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 Patient-Centered Lean Design

Value Orientation and Cultural

Transformation continued:
• Maintain a list of ongoing patient needs:
– Respect for their time
– Increased safety by decreasing medical errors
– Promote people to people interface between
patients and staff
– Create a healing environment that connects
mind, body, and spirit
Spiering, K, FacilityManagement.com, October, 2008

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 Patient-Centered Lean Design
Create a Value Stream Map (VSM) of
daily activities inside the hospital:
• Identify all the actions required from admission to
discharge and follow-up….a very complex matrix
• Examine the matrix with the staff to identify
procedures that really provide value to the patient
• Look at the non-value-added steps and try to
eliminate them with a different function,
technological improvement, or change in process
Spiering, K, FacilityManagement.com, October, 2008

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 Patient-Centered Lean Design
Transform the Lean VSM to an architectural
program with physical spaces that support and
enhance this new lean approach to healthcare
delivery:
• When you design around lean concepts, you design a
safer environment
• The leaner, safer, more cost-effective healthcare
environment incorporates a decentralized integrated
service delivery system
Spiering, K, FacilityManagement.com, October, 2008

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 Patient-Centered Lean Design
Orient services around the patient instead of requiring
the patient to travel to the service:
• Point-of-care testing
• Identical single bed rooms: everything is always located in
the same place to eliminate the possibility of staff error.
• Each patient room is its own work cell:
– Staff completes charting, dispenses medications, and
restocks supplies within the room
• The design allows for collaborative staff teaming:
– Team members move from patient to patient
– Supplies are regularly deployed to within two feet of staff
Spiering, K, FacilityManagement.com, October, 2008

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 Adaptable-Acquity Single-
Results:
Bed Rooms
• Lower nosocomial infection rates
• Fewer patient transfers and associated medical errors
• Less noise
• Better patient privacy and confidentiality
• Better communication from staff to patients and from
patients to staff
• Superior accommodation of family
• Higher patient satisfaction with overall quality of care.
Ulrich and Zimring, Sept 2004

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 Improve Ventilation
• Improved filters, high-efficiency particulate
air (HEPA) and others
• Appropriate pressurization
• Special vigilance during construction
• Results:
– Decreases acquired hospital infections
Ulrich and Zimring, Sept 2004

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 Improve Lighting and View
• Natural lighting, full-spectrum lighting, and
views of nature:
• Results:
– Decreased length of stay
– Decreased depression
– Better emotional well-being
– Improved sleep and circadian rhythm
– Decreased need for pain medication
Ulrich and Zimring, Sept 2004

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 Reduce Noise Levels to 35dB
• Single-bed rooms
• Install high-performance sound-absorbing
ceilings tiles and flooring
• Use noiseless paging
• Locate alarms outside patient rooms
• Results:
– reduce stress (decreased BP and HR)
– improve sleep
– Improve patient satisfaction
Ulrich and Zimring, Sept 2004

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 Develop Way Finding Systems
• Develop way finding systems that allow
users, particularly outpatients and
visitors, to find their way efficiently and
with little stress
• Results:
– Improves patient and visitor satisfaction
– Increases staff efficiency
Ulrich and Zimring, Sept 2004

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 Re-design Nurses Stations
• Reduce staff walking and fatigue
• Increase patient care time
• Support staff activities:
– Medication supply close at hand
– Communication
– Charting
– Respite from stress
• Results:
– Improved staff and patient satisfaction
– Decrease medical errors
Ulrich and Zimring, Sept 2004

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 Impacts of design elements
on patient safety
• Air quality directly impacts nosocomial infection
rates, as fungal load in the air is linked to
humidity and malfunction of the ventilation
systems
• Private patient rooms decrease the risk of
patients acquiring an infection when compared
to the risk in double occupancy rooms
• Improved lighting conditions decrease the risk of
medication errors
• Decreased noise levels cause decreased patient
disruptions and decreased length of stay
(Joseph, 2007).
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 Impacts of design elements on
staff working conditions
• High noise levels are linked to increased rates of fatigue
and burnout among nurses
• Unnecessary walking contributes to nurse fatigue and
reduces patient care time: the average nurse spends
30% of the working shift walking
• Easily accessible sinks and a high sink-to-bed ratio
increases rates of hand washing among clinical staff
(Joseph, 2007).
• Ceiling and portable lifts decrease the number of injuries
associated with patient lifting and handling
(Joseph, 2006).

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 Patient-Centered Lean
Design Results
• Sutter Health, Elk Grove, California
– Decreased staffing by 40%
– Decreased patient wait times by 50%
– Decreased building square footage by 30%
– Decreased Energy Consumption by 25%
• Virtua Health, Voorhees, New Jersey
– Increased patient safety
– Increased time staff spent on patient care
• Saint Joseph Community Hospital, West Bend Wisconsin
– Became one of the most patient-safe hospitals in the country.
Spiering, K, FacilityManagement.com, October, 2008

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Evidence Based Design Results
PeaceHealth Organization, Eugene, OR
• Installed ceiling lifts and booms in patient rooms in two
units (ICU and Neurology) of its existing facility 2006
• Virtually eliminated staff injuries caused from patient
handling
• Decreased cost of staff injuries caused from patient
handling by 99%
• Applying this data "house wide," they estimate that the
$1.64 million cost that they will spend making all 306
patient rooms in their new facility lift ready will be paid
back in approximately 1.88 years.
www.healthdesign.org/research/pebble/data.php

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Evidence Based Design Results
Parrish Medical Center, Titusville, FL
• New hospital 2002.
• Access to natural light, improved airflow,
separation of public/patient transport areas, and
"homelike" patient room design.
• Positively affected the quality of staff work-life
and help them provide care more effectively.
• Staff turnover decreased from 22% to 13%
– www.healthdesign.org/research/pebble/data.php

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Evidence Based Design Results
St. Alphonsus Regional Medical Center, Boise, ID
• Renovated a nursing unit in 2003 to test out the design
methodology it planed to use on a larger project
• Larger private rooms, added carpet to hallways, put
acoustical tiles on walls and ceilings, and relocated
machinery and nurse charting away from patients
• Quality of sleep improved from 4.9 to 7.3 (on a scale of
0-10)
• Patient satisfaction scores improved compared to a prior
three-month period.
www.healthdesign.org/research/pebble/data.php

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Evidence Based Design Results
Bronson Methodist Hospital, Kalamazoo, MI
• New out- and inpatient pavilions in 2000
• Private rooms, location of sinks, and air inflow design
• 11% decline in overall nosocomial infection rates.
• Decrease in patient transfers
• Nursing turnover rates are down to 4.7%.
• Occupancy rate has risen to 87%.
• Overall patient satisfaction increased to 96.7%.
• Market share has increased.
• Employee satisfaction has improved.
www.healthdesign.org/research/pebble/data.php

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Evidence Based Design Results
Methodist Hospital / Clarian Health Partners, Indianapolis, IN
• New Comprehensive Cardiac Critical Care 1999
• Acuity-adaptable rooms, patient room layout, equipment
integration
• Decentralized design to allow for better patient
observation
• Patient transfers down 90%
• Patient falls are down 67%
• Medication errors reduced 70%
• Unit design has helped reduce the caregiver workload
index, resulting in improvements in nursing efficiency
www.healthdesign.org/research/pebble/data.php
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Evidence Based Design Results
Barbara Ann Karmanos Cancer Institute, Detroit, MI
• Two inpatient units opened 1999 and 2000
• Increased space in medication room, location of
medication room, organization of medical supplies,
standardized visual cues, and acoustical panels to
decrease noise levels.
• Better visualization of patients due to angle of doorway,
improved lighting, and room layout.
• 30% reduction in medical errors
• 6% reduction in patient falls
• Patient satisfaction rose 18%.
• Nurse attrition rate fell from 23% to 3.8%.
www.healthdesign.org/research/pebble/data.php

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Results of new 100 bed community
hospital occupied 2003
• Private, single-patient rooms, 225 sq. ft
• Family area with futon
• Nurse workstation alcove
• Ceiling-mounted lifts in every room
• Consistent lighting
• Dust-resistant blinds
Ergonomics in Hospital Design. The Advisory Board, (June
2008)
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Results of new 100 bed community
hospital occupied 2003-cont.
• Hands-free faucets
• Humidity monitors
• Rubber flooring
• Same-handed rooms
• Results:
– Quieter noise levels
– Reduced severity (but not #) of patient falls
Ergonomics in Hospital Design. The Advisory Board, (June
2008)
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Results of new 100 bed community
hospital occupied 2003-cont.
• Going into the new facility, Staff Satisfaction was
very high
• One year after moving into the new facility, Staff
Satisfaction was at an all time low as was
Patient Satisfaction
• Currently, three years out, both Patient and Staff
Satisfaction are increasing steadily each year as
employees become more accustomed to the
new design and the quality of care improves
Ergonomics in Hospital Design. The Advisory Board, (June
2008)
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 Hospital of the Future

• Capacity Considerations:
– Be sure of the need to expand
– Use the impact of technology and practice changes
as well as demographics to project facility needs
– Anticipate the downstream impact of expansions; ED
Expansion on CT, ICU, and Med Surg
– Provide for Interventional Flexibility: shelled in space
and pre-wired expansion capability to accommodate
future changes in volume, mix, and technology
Hospital of the Future, The Advisory Board, (2007)

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 Hospital of the Future

• Space Planning:
– Private rooms are the standard of care
– Facility specialization is the enemy of efficiency and
flexibility. Strive to create general purpose ORs,
ICUs, ED rooms, and Inpatient rooms.
– Move support functions to non-hospital grade space
– Consider moving non-acute clinical functions outside
the hospital walls.
Hospital of the Future, The Advisory Board, (2007)

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 Hospital of the Future
• Space Planning continued:
– Design modified acuity-adaptable rooms that offer
flexibility and decreased transfers
• Preferable to the zero-transfer model (universal room model)
• Continue to use the ICU: Combine Med-Surg with PCU to
make the modified acuity-adaptable unit;
– Up-skill the Med-Surg nurses to Acuity-Specialty
nurses
Hospital of the Future, The Advisory Board, (2007)

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 Hospital of the Future

• Design Elements:
– Space agility should be a top priority: to be able to
repurpose space to accommodate fluctuating
demand, especially in departments with volatile
volumes
– There is no right answer for inpatient unit
configuration: many options exist and none is ideal
from every vantage point
– Use semi-decentralized nursing stations to bring
nurses closer to patients but allow peer interactions
with use of a small centralized area.
Hospital of the Future, The Advisory Board, (2007)

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 Hospital of the Future

• Design Elements continued:

– Encourage shared prep and recovery spaces in the
operating room area
– Place interventional and surgical rooms on the same
floor to provide versatility to accommodate future
changes in the mix of those volumes
Hospital of the Future, The Advisory Board, (2007)

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 Four Worthy Design Principles
1. Semi-decentralized nursing stations:
• Small central station for interdisciplinary caregiver
communication with dispersed work stations for
nursing documentation
2. Room Design Standardization:
• Single patient rooms
• Sink by the door: same place for every room
• Consistent supply storage: same place, same
drawer in every room
• Mirrored headwalls: standard gases and alarms in
same location on both sides of bed
Hospital of the Future, The Advisory Board, (2007)
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 Four Worthy Design Principles
3. Ample In-room Family Space:
• In-room Sleeping Accommodations: 40 sq ft
family zone concept (Kaiser Permanente)
4. Accommodations for Obese Patients:
• Wider “break-away” doorway (61” doors)
• Floor mounted toilets
• Built-up shower stall to allow for wheel-chair access
• Ceiling Lifts (800 lb capacity)
Hospital of the Future, The Advisory Board, (2007)

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 Unit Configuration
• Equipment service center:
– Located in non-critical off-unit space
– Manned by equipment techs
– Receive nurse orders by phone and deliver to unit
within 15 minutes
– Round twice per shift for soiled equipment.
Hospital of the Future, The Advisory Board, (2007)

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 Technology Needs
• Build Flexible IT Infrastructure:
– Over-wire the walls
– Seamless wireless signal coverage is
essential
– Facility-wide RFID infrastructure need to track
objects
– Build Technology Closets throughout the
hospital 5X8 up to 10X10 with temp
monitoring
Hospital of the Future, The Advisory Board, (2007)

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 Use Flexible Design to allow
Future Change
• Concentrate on robust vertical and horizontal circulation
routes
• Recognize the importance of integrated work flows
between diagnostics and treatment
• Regard waiting as an educational opportunity
• Use technology to provide information to patients and
staff to support a speedy journey through treatment
• The overall layout needs to promote patient safety,
create the best working environment and recognize the
unique needs of patients

Hospital of the Future, The Advisory Board, (2007)

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 Top 10 List of Evidence
Based Design Features
• Single patient rooms
• Installing HEPA filters
• Providing access to nature
• Installing ceiling lifts
• Installing sound-absorbing ceiling tiles
• Family areas within patient care spaces
• Providing access to sunlight
• Promoting the use of visible and accessible hand-
washing dispensers
• Promote visual access and accessibility to patients
• Providing areas of respite for staff
Center for Advanced Healing, Saint Alphonsus Regional Medical
Center, Boise, Idaho 2008
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 Key messages

• “Lean thinking” needs to engage decision makers,

clinical staff, managers, health planners, and designers
• Need to move from isolated good practice to whole
systems pathways and system reform
• Sharing information about good practice is urgently
needed
• The potential for technology to assist needs to be further
developed
• The implications of system redesign for the design of the
physical environment needs to be better understood
• Both clinical and design staff could benefit from training

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 References
• Hagood, Charles, leanhealthcareexchange.com,
• Anita L. Tucker and Steven J. Spear, Operational Failures and
Interruptions in Hospital Nursing, Health Research and Educational
Trust, 2006, pp. 1-20.
• Rutherford, P, Value Added Care Process, IHI presentation, Feb 2008
• Spiering, K. FacilityManagement.com, (Oct 7, 2008)
• Ulrich and Zimring, Designing the 21st Century Hospital Project, The
Center for Health Design, Sept 2004
• Joseph, A. Current Opinions in Critical Care. (2007)
• Joseph, A. Healthcare Design. (March 2006
• www.healthdesign.org/research/pebble/data.php
• Ergonomics in Hospital Design. The Advisory Board, (June 2008)
• Hospital of the Future, The Advisory Board, (2007)
• Center for Advanced Healing, Saint Alphonsus Regional Medical
Center, Boise, Idaho 2008

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 Useful Web Sites
• Advisory Board—www.advisory.com
• AIA-Institute of Architects-www.aia.org
• Building Design and Construction- www.bdcmagazine.com
• Building—www.building.com
• The Center for Advanced Healing--
www.saintalphonsus.org/CenterforAdvancedHealing.html
• The Center for Health Design--www.healthdesign.org
• Pebble Project--www.healthdesign.org/research/pebble/data.php
• IHI—www.ihi.org
• Contract—www.contractmagazine.com
• Facility Management—www.facilitymanagement.com
• Health Affairs—www.healthaffairs.com
• Health Facilities Management—www.hfmmagazine.com
• Modern Healthcare—www.modernhealthcare.com
• Wall Street Journal—www.wsj.com

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Thank You

Questions?

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