Updated: May 6
We have all heard the phrase transforming health care. Some of us have even personally experienced transformation in care as patients through improved work flow generated by Lean and other methods of process improvement. But how does this concept apply to your built environment and what is the value that this brings to your organization?
In the last decade we have all become acutely aware of the forces driving change in health care delivery as embodied in the Institute for Health Improvement’s Triple Aim: Better care for individuals, better health for populations, and lower per capita cost.
Innovative health care organizations have responded by streamlining and improving patient care and by changing the way they develop and manage their built environment. Facility design must support health care operational improvements. While Lean process improvement methods frequently result in excellent design solutions, these methods often fail to incorporate the creativity and benefits of a time-honored standard: Design Thinking.
Many of the health care organizations we work with responded to this challenge by embracing a design process built around Integrated Facility Design (IFD) that integrates Lean and other process improvement methods with Design Thinking to align organizational initiatives with facility design. The success of this effort is highly dependent upon fulfillment of three objectives: Behavior and practice change, operational improvement, and facility design. Integrated Facility Design combines these three objectives.
The Lean process improvement method, originally developed around industrial production, has been successfully adapted to many service industries including health care. Many Lean tools are variants of time-tested quality improvement techniques and are widely used in other quality improvement methods. (Image courtesy CSP Fast Pass: Focus on Flow)
In 2002 Lean was the new kid on the block in health care. Several organizations adopted Lean methods and thinking and used Lean improvement tools while other organizations embraced alternative process improvement methods and tools to sustain their transformation.
Case In Point
Several years prior to Virginia Mason adopting lean as their operating model, I managed the design team for Virginia Mason’s Ambulatory Surgery Center in Federal Way, Washington. How did the design team create and communicate a successful layout to their client? We employed the flow map below to show how patients, providers, instruments, and supplies would move through the space with minimal waste. As planners, we are trained to understand flow. And we employed design thinking to generate the best solution possible.
(Diagram courtesy NBBJ Design)
The Lean process improvement method, originally developed around industrial production, has been successfully adapted to many service industries including health care. Many Lean tools are variants of time-tested quality improvement techniques and are widely used in other quality improvement methods.
Design thinking requires careful consideration of how things could be and ways to transform existing situations into more desired ones. Process improvement and design thinking share the same goals and often the same tools. However, a major attribute of the design mindset is to be solution-focused and action-oriented and not problem-focused.
Design thinking can best be described as a discipline that uses the designer’s sensibility and methods to match people’s needs with what is technologically feasible and what a viable business strategy can convert into customer value and market opportunity.
Tim Brown, CEO of IDEO
Some people think design means how it looks. But of course, if you dig deeper, it’s really how it works.
Positive change requires innovation and that requires a thorough understanding of your unmet and often tacit needs. With this understanding the design team embarks on a journey of discovery leading to the best solution. This is not a linear process: It’s iterative, relying on experimentation and incremental improvement. If this process sounds familiar, recall Deming’s Plan-Do-Check-Act (PDCA) improvement method. Design thinking employs scientific methods and creativity to explore the possibilities of what could be, and deliver results that fulfill your requirements.
To illustrate this concept here are reviews of three similar approaches to Design Thinking.
One of the most graphic illustrations of the design process is the Squiggle Diagram created by Daniel Newman of the Central Office of Design, Sausalito, CA. The diagram represents a transformation from uncertainty to clarity using design thinking.
(Diagram courtesy Central Office of Design/Daniel Newman)
To many, the design process is a mystery, with creative types practicing their craft single-handedly in a design studio. However, even without the captions, the above diagram tells a different story. The process can be described as:
Define the challenge
Do the research
Create the design
And by iterating through this process you create continuous imporevement.
These are team-based actions involving everyone associated with the project.
Continuous improvement is the key phrase that describes how design works. Design is an iterative process that embraces continuous refinement of creative solutions. The squiggles eventually resolve to a wavy line and finally to a straight line.
Designing for Growth
In their publication “Designing for Growth”, Jeanne Liedtka and Tim Oglivie present the design thinking process in an ostensibly linear fashion, as a series of four questions. Their goal is to decode the design process: From abstract to practical, from thinking to doing, and from analysis to experimentation.
(Diagram courtesy “Designing for Growth” by Jeanne Liedtka and Tim Oglivie)
The central theme of this model is divergent and convergent thinking. It recalls the Lean 3P workshop wherein teams are encouraged to use convergent thinking to describe current-state and divergent thinking to guide innovation and to create a construct of how things could be in a future state.
The first question: What is?
Assess current-state in order to frame the design challenge
Understand and visualize the client’s needs
Second question: What if?
Establish design criteria and draw upon nature for potential solutions
Envision choices for a new future: How things could be
Third: What wow’s?
Choose the most effective solutions
Exhibits a wow factor that is appealing to users
And fourth: What works?
Test the design solution
Take the design to the marketplace
The diagram below from the Design Council (UK) also illustrates the divergent/convergent thought process used in design thinking:
(Image courtesy The Design Council, UK)
The Design Council’s approach to design is straightforward, based on a logical progression of four action-oriented steps: Discover, define, develop, and deliver.
Each one these approaches defines a process based on design thinking and employs critical thinking and Lean process improvement methods at strategic intervals. Design thinking and process improvement are interdependent, each providing a structured framework for problem-solving and customer-focused solutions.
Integrated Facility Design: Bringing It All Together
How do Integrated Facility Design and process improvement methods complement each other? The greatest advantage of IFD is that the process integrates the expertise of all stakeholders to achieve breakthrough improvements. The stakeholders may include patients and their families, hospital administrators, physicians and surgeons, nurses, staff, the design team, the general contractor, and operational excellence experts.
By leveraging the collective intellect of all the participants, the IFD team is better equipped to solve a complex design problem and is enabled to visualize their future built environment. Even more important, the iterative nature of this design process produces lasting results.
Our IFD strategy integrates operational improvements and facility planning by focusing on:
Change management: We facilitate your people working together in a collaborative, transformed practice
Operational Improvement: We lead a process of discovery whereby you redefine and improve flow by eliminating operational waste and focusing on more efficient delivery of patient care
Facility planning: We facilitate the creation of standard, adaptable spaces that enable the operational improvements defined by you
Our design approach was created in response to an unpredictable marketplace working with organizations who were choosing to align with design teams who really understood their business and market position. These organizations wanted partners who really understood the needs of patients and care teams. They wanted planners and facilitators who could help implement organizational change.
Moving The Curve
The chart below shows how Integrated Facility Design can move the curve and reduce waste and project cost by tying down the design earlier in the process leading not only to significant savings early on but through the life of a completed project.
Experience shows that the time invested in IFD workshops (green dotted line) yields a pre-schematic layout that jump-starts the entire design process, trimming significant production time from the project schedule and minimizing design changes along the project timeline.
The Integrated Facility Design Workshop
What happens in an IFD workshop? By blending design thinking and process improvement tools a customized plan for your project/process improvement is created. Key workshop elements in a three-day event include:
A full three-day IFD workshop employs the following process improvement methods and tools:
Visioning: Guiding principles; community involvement
Observation: What we heard; what we observed
Analytics: What we know; patient volumes; market opportunities
Quality Improvement: Optimizing flow; visual control; communication; case studies
Waste Reduction: Identify current-state process waste; 8-Wastes
Current-State Flow: Flow maps to show how it’s done now; identify wasteful steps; 7-Flows
Innovation: 7-ways innovative thinking; future-state ideation
Future-State Flow: Design and map new flow; eliminate waste; develop patient-centric designs
Key Adjacencies: Organize spaces; test adjacencies; test flow prior to test-fit layouts
Test-Fit Layouts: Use standard, scaled templates; refine adjacencies based on flow; test flow
Rapid Prototyping: Construct full-scale mock-ups; cellular and modular design; locate key elements
Simulation: Scenario planning; script standard work; create flow map; run multiple scenarios
Implementation: Create momentum map; draft implementation plan; draft communication plan
Additional tools are employed when required and may include: Set-Based Design, Standard Ops, PDCA, Value Stream Maps, Quality Function Deployment templates, and A3 storyboards. The underlying goal for the use of these tools is that design should be based on optimal flow that reflects the best of your organization.
Re-engineering processes alone will not resolve the challenges facing the health care industry. Health care organizations need to integrate facility redesign into process improvement to gain full value. The design profession is prepared to employ design thinking and the design tools required to face these challenges.
With over twenty certified Lean leaders in our organization we have integrated Lean processes and tools into our design practice and have worked with, and learned from, the most forward thinking health care organizations. We are built upon design thinking principles and fully committed to continuous quality improvement.