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RxRE: Lean Thinking In Healthcare

RxRE: Lean Thinking In Healthcare

Slides from Colliers International |Boston's RxRE: Lean Thinking in Healthcare seminar. February 28, 2013


  1. Welcome February 28, 2013 PANELISTS Walter G. Armstrong Senior Vice

    President, Capital Facilities & Engineering Beth Israel Deaconess Medical Center Wendy Writer Gettleman Vice President, Facilities Management & Real Estate Dana-Farber Cancer Institute John Messervy, AIA Director of Capital & Facilities Planning Partners HealthCare William R. Seed Staff Vice President, Design & Construction Department Universal Health Services MODERATOR Daniel R. Quinn Executive Vice President, Development & Consulting Services Colliers International
  2. John Messervy, AIA Director of Capital & Facilities Planning Partners

  3. RxRE: Lean Thinking in Healthcare

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  7. Tools to Assist in Lean Process Design Time Study RN

    PDA Data Collection
  8. Hospitalist Activity Breakdown 37.6% 16.6% 14.2% 13.2% 12.9% 4.1% 1.4%

    Writing Progress Note Chart Review Writing Orders Comm. w/ MD Patient Care Conf. By Nurse Station Activity 60.9% 13.9% 11.3% 6.1% 6.1% 1.7% Daily Rounds Subsequent Visit Admission Dishcarge Family Meeting Teaching By Patient Room Activity
  9. Euclidian Model The Centralized Nurse Station model requires multiple trips

    to and from the Nurse Station and Patient Room.
  10. 60.7% of all trips for RNs / CNAs / Techs

    involve those to and from the Patient Room and Nurse Station. Travel Density
  11. • Transition from centralized nurse stations to decentralized care delivery

    model • Decentralized supplies • Decentralized workstations • Medications decentralized to cabinets outside of each patient room PDA Data Informs Design of the IP Unit
  12. Lean Design Reduces Travel by 51% 0 5,000 10,000 15,000

    20,000 25,000 Davenport 7 Davenport 9 West 1 Final Option 23,229 18,046 21,207 11,345 Estimated Travel Distance (Ft per Hr by Nurses) Existing Inpatient Units New Inpatient Design 11,884 Feet/Hour Travel Reduction
  13. 6 beds 6 beds 6 beds 5 beds + 1

    Isolation 5 beds + 1 Isolation 5 beds + 1 Isolation Design Impact on Care Delivery & Functionality 12 Bed Pod 12 Bed Pod 12 Bed Pod 36 beds grouped in 3 clusters of 12 based on hospitalist and nursing staffing models New Lobby below Public Elevators Patient Elevators
  14. Space Creep

  15. Ellison Bldg (1992) Lunder Bldg (2011)

  16. Unit Cost Shell & Core Fit-out 1998 $158/sf $177/sf 2005

    $296/sf $262/sf 2009 $428/sf $323/sf Project Cost Schematic Design: $117M $354/sf Design Development: $129M $343/sf GMP: $134M $353/sf Complete: $144M $379/sf - Increase: $ 27M $ 25/sf Delivered 2 months late Cost Creep
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  18. Why is Lean Design and Construction Attractive to an Owner?

    • Reduced risk • Improved management of project costs • Supports making sound decisions • Promotes the accumulation and sharing of knowledge
  19. Walter G. Armstrong Senior Vice President, Capital Facilities & Engineering

    Beth Israel Deaconess Medical Center
  20. The Unique Contribution of a Lean/Toyota Production System Approach to

    Design & Construction February 28, 2013
  21. Lean is an effective tool in making hospital operations more

    efficient. Background in engineer-led, heavy construction projects influences view Context: 21
  22. • Integrated team with early collaboration among designers, constructors, commissioning

    agents, etc. • Early and ongoing involvement of key stakeholders • Value engineering, constructability and operability reviews • Design software used to increased construction efficiencies and maintain quality control • Progressive contracting practices • Many more What Does Lean Expertise Bring to Design and Construction that Cannot be Gained by Improved Project Delivery Techniques such as:
  23. • East Campus Pharmacy upgrade $ 2.2 M • Pre-Admission

    Testing Center $ 4.4 M • Western Cancer Center $ 32.0 M Application of Lean Expertise to Design Construction
  24. • Pharmacy – sub-consultant on design team • Pre-Admission Testing

    Center – expert as part of architectural team • Western Cancer Center – separate contract with the owner, coordinating with other team members and stakeholders Different Placement of Lean Expertise on Design and Construction
  25. • 20 front-line staff off-line for a week • “Gemba”

    walks of current space • Value stream map of current workflows • Work Breakdown Structure • Map IS flow process and document management Sample Lean Exercise: Pharmacy
  26. • Conduct Rapid Improvement exercises • Tour off-site locations for

    best practices • Define standard work • Establish metrics • Define future workflows Sample Lean Exercise: Pharmacy
  27. • Designed equipment layout on paper with multiple teams •

    Arranged full-sized equipment models on full-scale floor layouts • Each team’s layout was video taped and reviewed by all participants • Each team did 3 layouts in sequence followed by group discussions • Consensus reached on equipment layout Sample Lean Exercise: Pharmacy
  28. Day 3 • DESKTOP EXERCISES Layout to Scale


  30. • Focus on GEMBA (“where the work is done”) •

    Involvement of front-line staff • Structuring the input of front-line staff through standard tools and techniques • Understanding and improving the workflow prior to hardened design concepts • Obtaining input from the customer Enhanced Benefits of Lean
  31. • Finding Lean experts skilled in design, not operations •

    Finding Lean experts comfortable in working in the engineering/construction environment with its emphasis on cost and schedule • Finding architectural firms which have integrated operations experts/industrial engineers into their practice • Assisting front-line employees to conceptualize new workflows in new spaces, rather than improving workflows in existing environments Challenges
  32. Wendy Writer Gettleman Vice President, Facilities Management & Real Estate

    Dana-Farber Cancer Institute
  33. Yawkey Center for Cancer Care LEAN process: design through occupancy

  34. Yawkey Center for Cancer Care Designed by patients, families and

    staff, for patients, families and staff. It all started with our design principles: 1. Promote personalized, multidisciplinary, safe, respectful, compassionate cancer care for patients and families in a healing environment 2. Stimulate translation of research into the care of patients 3. Optimize flexibility and utility of space 4. Streamline the flow of patients and materials, minimize wait and treatment times 5. Foster productivity and collaboration of staff 6. Create a new front entrance and presence
  35. Yawkey Design Process 2006 - 2007 Established user groups to

    inform design process > 30 design committees & user groups > 300 participants in planning & design process including: Defined decision makers & roles • user groups and committees informed • 2020 group packaged clinical decisions • Steering committee provided recommendations • Leadership Triad made timely decisions • More than 25 MDs • More than 25 RNs • More than 30 patient and family members • More than 250 DF/BWCC employees
  36. How is this LEAN design? LEAN is all about process

    improvement ~ Pulling patients, family members, staff and leadership together to: › establish project goals › define and remove waste & “work arounds” › incorporate safe design features › then integrate what we learn into the design
  37. LEAN tools used during design, construction & post occupancy Lab

    Services (Phlebotomy) Goal: Streamline the flow of patients and materials, minimize wait and treatment times During design: simulation exercises with Tefen to understand flow and impacts of Centralization During construction: get it right the first time! Limit & manage change orders. Communicate. Coordinate. Work as a team. Post occupancy: Kaizen with staff & patients to review flow and opportunities for improvement
  38. Public side Staff Consult rooms Bridge Exam Infusion vitals Check

    out Check in Challenges • Staff turn-over between design & occupancy • Hard to imagine and plan operational change so far in advance (2006-2011) • Last minute operational changes • New technology + new space = higher hurdles Overcome these challenges by: • documenting assumptions & decisions as they are made • revisit these decisions during operational planning • work through operational needs as a team to limit change Meeting space
  39. Measuring success • Under budget & occupied ahead of schedule

    • Press Ganey scores in the 90s - higher than ever! • Association of General Contractors (AGC) National Build America Award for “New: Construction Management” & AGC Build New England Honor Award • Boston Society of Architects (BSA) Healthcare Facilities Design Award 2013 • Construction Management Association of America (CMAA), New England Chapter, Project Achievement Award for New Building Construction over $200M • American Council of Engineering Companies of Massachusetts (ACEC/MA) Silver Engineering Excellence Award • Deep Foundations Institute National First Runner-up for the Outstanding Project Award • Modern Healthcare Design, Design Citation Award • International Interior Design Association New England (IIDA) – Healthcare Project Award • LEED Gold certification
  40. William R. Seed Staff Vice President, Design & Construction Department

    Universal Health Services
  41. RxRE: Lean Thinking in Healthcare

  42. Manatee Memorial Hospital 2007 • $17MM over budget • 1

    year delayed
  43. Texoma Medical Center 2007-2009

  44. A3 thinking, collaboration, real team work, reliable promises, open communication,

    waste ID
  45. Daily huddles, dabbled in pull planning, advanced retrospective, kaizen, critical

  46. Texoma Medical Center Conditions of Satisfaction • Reduce cost by

    $4 million – overall goal is $94 million • Deliver project in 17 months – November 2009 • No punch list • No injuries • No rfi’s • No change orders • No rework Conditions of Satisfaction • Final construction cost was $97.9 million • $1.7 million in savings pool • $7 million in value adds • Project delivered first week in December despite 87 rain days • No punch list at owner turn over • Only 4 minor recordable injuries • 190 rfi’s • 40 related to early steel package • Many were confirming • $1.4 million in change orders • $1.1 million was owner driven • Rework greatly minimized through collaborative efforts
  47. Lean Journey continues late 2008

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  49. • 80 beds/58,000 sf • $213/sf construction cost • $279/sf

    all in cost • $205k per bed • $249/sf if built in KY • $231k per bed Springwoods BH Fayetteville, AK 2008
  50. Cumberland Hall Hopkinsville, KY 2011 • 100 beds/68,000 sf •

    $184/sf construction cost • $250/sf all in cost • $171k per bed • $184/sf built in KY • 30% less cost
  51. IPD Experience • 50 Projects IPD-ish • $1MM to $150MM

    • 18 completed • Results: Outstanding • 17 under construction • Watching efficiencies improve daily • 15 in design phase • Phenomenal collaboration, Learning, BIM, Results • 28 Full Consensus Doc 300 IFOA
  52. Temecula Valley Hospital 2013 • 40% below market cost •

    30% operational cost improvement • 200%+ increase in labor productivity • 7 IFOA partners • Rapid improvement • Exceptional team work • Lots of FUN
  53. Published late 2011 • All projects $5MM + IFOA •

    Partnership Charter • Training Curriculum • Regionalized vendor pool • Benchmark project target pricing • High Expectations
  54. Q&A

  55. Thank you!