Applying Lean Thinking and Principles in Building Design by pengxuebo

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									Applying Lean Thinking and
Principles in Building Design




Bob Breen, Chief Project Officer
Provincial Health Services Authority
C&W Redevelopment Project

November 2011
C Children’s and Women’s Redevelopment Project
 About Provincial Health Service Authority
 (PHSA)

PHSA plans, manages and evaluates specialty and province-wide
health care services across the province of British Columbia

                                                     BC Children’s
                                                                              BC Women’s
                              BC Center for          Hospital and Sunny
  BC Cancer Agency                                                            Hospital and Health
                              Disease Control        Hill Health Center for
                                                                              Center
                                                     Children




  BC Provincial Renal
                              BC Transplant          Cardiac Service BC       Perinatal Service BC
  Agency




  BC Mental Health & Addiction Services (including   Emergency and
                                                                              Health Shared
  Riverview Hospital & Forensic Psychiatric          Health Service
                                                                              Services BC
  Services)                                          Commission



                                                 2
Children’s and Women’s Health Center
Redevelopment Project

                        •  A replacement of current
                           Children’s inpatient
                           building, and BC Women’s
                           NICU and Birthing Suite

                        •  Three phases
                           –    Demolishing and relocation
                           –    Acute Care Center
                           –    Renovation


                        •  Estimated $682 M Total




                  3
Lean in PHSA, Children’s and Women’s Hospital


 •  PHSA has been on Lean journey for almost 4 years

 •  82 RPIWs (Rapid Process Improvement Workshops) in
    Children’s & Women’s Hospital in these 4 years

 •  Areas that had RPIWs include but not limited to:
    –    Women’s maternity service line
    –    Neonatal Intensive Care Unit
    –    Children’s Pediatric Intensive Care Uint
    –    Children’s Emergency Department
    –    Children’s Surgical Service Line
                                 4
What is Lean?



PHSA Definition - Lean is a mindset of
 continuous improvement. It’s a system
 that empowers people at all levels to:
    •  Remove waste
    •  Maximize what is of value to the patient.




                       5
8 Wastes - DOWNTIME


•    Defects – medical errors
•    Overproduction – excessive lab tests
•    Wait – wait to be seen by physician or exam
•    Non-utilized staff – intellectual waste
•    Transportation – transport patient from unit to unit
•    Inventory – store more than what is needed
•    Motion – search for information
•    Extra-processing – re-do exams or tests



                             6
5 Principles of Lean

• Define value
• Identify the value stream   No Error
• Make the process flow       No Waste
• Pull from the customer      No Problem
• Head toward perfection




        Perfection



                         7
1st Chapter of Applying Lean In C&W Site Redevelopment Project


                     3P workshops
What is 3P?

•  Production Preparation Process

•  Data driven qualitative and quantitative analysis to
   inform design decisions

•  Often used when
   –  Designing new facilities or layout
   –  Adding new service lines or products
   –  Creating new processes or changing providers

                            8
Applying Lean In C&W Site Redevelopment Project
3P workshops
•  4 workshops focused on high level of service flows
   –    Flow of C&W site wide services
   –    Flow of patient arrival, planned and unplanned
   –    Flow of Inpatient services
   –    Flow of procedures & interventions requiring sedation or
        anesthesia


•  Involves teams of 40 to 50 people from across the
   organization

•  Programming and Space Planning is condensed into one
   week but preceded by data collection
                                9
 3P event preparation

                                   -3P Project Form-

•    Identify event leaders from   3P Project Name:                     Macro Flows and Service Relationships Across C & W including SHHC                       3P Date:       September 20-24,
                                                                                                                                                                               2010

     the organization              If linked to past project, note 3P # & Project Name here:

                                   Sponsor/Process Owner:                           Larry Gold                        Current State
                                                                                    Jan Christilaw
                                   Team Leader/s:                                   Barb Fitzsimmons
                                                                                                                       The BC Children’s and Women’s Hospital is in the process of planning for the
                                                                                    Jan Christilaw
                                                                                                                       design and development of a new Acute Care Centre (including clinically-
                                                                                                                       based academic space to support clinical teaching). The redevelopment
                                   3P PI Support:                                   Kent Riopelle (Lead)
•    Define scope of the event                                                      Jane Sun
                                                                                    Brendan Abbott
                                                                                                                       project aims to improve the delivery of service to the patient/family and the
                                                                                                                       overall flow through design and physical plant improvements in a new Acute
                                                                                                                       Care Centre.
                                   Content Experts (if applicable)                  Department
                                   1. TBD                                                                              The context for planning the new Acute Care Centre will take into
                                   2. TBD                                                                              consideration both the services that will be housed in the new building as well
                                   Team Members (~ 25 Participants) Must be present all 5 workshop days                as those services that will be located in other parts of the campus that will
                                   to qualify as a Participant; Up to 25 Participants required                         interface with the new building. The aim is to ensure the best possible flows
•    Identify team members –       BCWH DST (or designate)
                                   Alain Gagnon (DAP)
                                   Cheryl Davies (DAP)
                                                                             BCCH DST (or designate):
                                                                             John Hope (Pharmacy)
                                                                             John Masterson (Surgery)
                                                                                                                       are achieved across the total campus. To this end, the major component
                                                                                                                       services which are planned to be studied during this event include:

     between 35-45                 Brian Lupton (Critical Care)
                                   Julie De Salaberry (Critical Care)
                                   Pam O’Sullivan (Acute Perinatal)
                                                                             Douglas Matsell (Medicine)
                                                                             Deborah McFadden (Labs)
                                                                             Nancy Lanphear (SHHC)
                                                                                                                       •
                                                                                                                       •
                                                                                                                           Emergency services
                                                                                                                           Sterile processing

     multidisciplinary team
                                   Wendy Newson (Acute Perinatal)            Becky Palmer (Professional Practice,
                                   Roanne Preston (Anesthesia)               R&D)                                      •   Radiology and diagnostic imaging services (C&W)
                                   Ellen Giesbrecht (OB&GYN)                 Kathy Rasmussen (Patient Care Svs)        •   Diagnostic and treatment services interventional suite
                                   Deborah Money (Women’s Health)            Eleanor Reimer (Anesthesia)

     members                       Nancy Kotani (Inter-hospital Svs)
                                   Mental Health:
                                   Betty Kerray
                                                                             Ralph Rothstein (Medicine)
                                                                             Pam Berekoff (Radiology)
                                                                             Fran Boyd (SHHC)
                                                                                                                       •
                                                                                                                       •
                                                                                                                           BC Children’s Surgical Services
                                                                                                                           Academic teaching space
                                   Project Team:                             Alecia Robin(Patient Care Svs)
                                   Bob Breen (Project Officer)               Vicky Crompton (Patient Care Svs)         •   MDU, MIF, Renal Dialysis
                                   Diana Robinson (Project Support)          David Wensley (Critical Care)             •   70 bed Neonatal Intensive Care (NICU)
                                   Cathy Helliwell (PHSA)
                                   Marsha McCall (Project Director)          Others:                                   •   Pediatric Intensive Care Unit (PICU)

•    Establish information/data    Eleanor Lee (Project Director)
                                   Support:
                                   Karyn Epp (DSS)
                                                                             Bob Billington (Functional Planner)
                                                                             Stuart Rothnie & John Jex (Architects)
                                                                             Patient/Family Rep
                                                                                                                       •   Labour/Delivery Suite (LDR rooms and C-section suite)
                                                                                                                       •   Inpatient medical-surgical beds (including inpatient acute rehab beds)
     requirements
                                   Scott MacRae (DSS)
                                   Ognjenka Djurdjev (DSS)                                                             •   Oncology inpatient beds plus an oncology outpatient and day care
                                   Jennifer MacKenzie (PHSA)
                                                                                                                           program
                                   ImPROVE (TBD, PHSA)




                                       10
       4 weeks prior to the event
       •  Value Stream Map (current) – understand current patient journey
          and identify the wastes in the system
       •  PQ analysis - understand patient population
       •  Time study (CT, LT, TT) – inform the service requirement

                                                                                                                                                                                                                                                                                                                                                                                          Value Stream Map
                                      Radiology - Vascular Special Procedure (Sedated)                                                                                                                                                                                                                                                                                                    BCCH Emergency
                                                                                                                                                                                                                                                                                                                                                                                                                                       Central

                                                         2009/2010
                                                                                                                                Child requires medical                                                                                                                                                                                                                                                                                computer
                                                                                                                                       attention                                                                                                                                                                                                                                                                                       system




 300                                                                                                                     100%                                                                                                                                                               Level Load Exam rooms
                                                                                                                                                                                                              Streamline Triage process
                                                                                                                                                                                                                                                                                            - flexibility of space
       244                                                                                                               90%                                                                                  - single step
                                                                                                                                                                                                              - RN / MD triage                                                              - used for exams, consults,
                                                                                                                                                                                                                                                                                                                                                                                                 Decrease wait time for
                                                                                                                                                                                                                                                                                                                                                                                                 specialist consultation
 250                                                                                                                                         Walk In
                                                                                                                                                                                                              - active waiting room                                                            procedures
                                                                                                                         80%
                                                                                                                         70%         Physician Referral
 200
                                                                                                                         60%
                                                                                                                                                                                                                                                                                                                                                                       Intern / Resident / Fellow
                                                                                                                                          Ambulance                                         RN Pre-Triage                                        Clerk Registration                                 RN Triage                            Nurse assessment                                                  MD Assessment
 150                                                                                                                     50%                                                                                                                                                                                                                                                 asssessment
                                                                                                                                                                                    Cycle Time (min)          1                           Cycle Time (min)         3 - 5 min               Cycle Time         5 - 25 min             Cycle Time        14 min         Cycle Time (min) 5-60 min      Cycle Time (min)    5 - 60 min

                                                                                                                         40%                                         0 - 5 min      Batch Size             1 patient     0 - 20 min       Batch Size               1 patient   0 - 120 min Batch Size         1 patient    0-240 min Batch Size       1 patient   ?   Batch Size       1 patient     Batch Size          1 patient

 100                                                                                                                                        Transfer                                                                                                                                       Est. Daily                                Est. Daily

             67 59                                                                                                       30%                                                        Est. Daily Volume
                                                                                                                                                                                    Patient name and time
                                                                                                                                                                                                          112                             Est. Daily Volume
                                                                                                                                                                                                                                          Name & ID
                                                                                                                                                                                                                                                                     112                   Volume
                                                                                                                                                                                                                                                                                           Visit Reason
                                                                                                                                                                                                                                                                                                                 112                 Volume
                                                                                                                                                                                                                                                                                                                                     Detailed info
                                                                                                                                                                                                                                                                                                                                                        112           Est. Daily Volume
                                                                                                                                                                                                                                                                                                                                                                      Assessment
                                                                                                                                                                                                                                                                                                                                                                                           112       Est. Daily Volume
                                                                                                                                                                                                                                                                                                                                                                                                     Assessment
                                                                                                                                                                                                                                                                                                                                                                                                                            112

                                                                                                                                                                                    Reason for visit                                      Assess cont                                      Assess cont                               Assessment                       Diagnosis                      Diagnosis
                     40 40                                                                                               20%                                                        Eyeball exam                                          GP                                               Vital signs                               Observations                     Observation                    Observation
 50                          26 20 20 20 19 17                                                                                                                                      Documentation                                         Allergies
                                                                                                                                                                                                                                          Infectious precautions
                                                                                                                                                                                                                                                                                           Chest assessment
                                                                                                                                                                                                                                                                                           Initial protocol
                                                                                                                                                                                                                                                                                                                                                                      Treatment                      Treatment

                                               14 10     9                                                               10%            Air Ambulance
                                                             5   5   5   3   3   2   2   2   1   1   1   0   0   0   0
                                                                                                                                                                                                                                          Insurance                                        Health history
                                                                                                                                                                                                                                                                                           Immunizations

  0                                                                                                                      0%
                                                                                                                                        Planned Visits                 2.5                                                10                                                      60                                       120
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                                                                                                                 11
Event Week

•  Lean Education
•  7 Ways Exercise to warm up
•  Review data and current state flow to identify waste




                              12
Event Week - Understanding Current Service Flow

•    Flow of Patient
                                       Tracking flows on
•    Flow of Providers
                                       current building
•    Flow of Medication
•    Flow of Information
•    Flow of Equipment
•    Flow of Supplies
•    Flow of Process
     Engineering
•    Flow of Family
•    Flow of Food


              Tracking Activities on
              Takt Time Map
                                 13
Developing Future Site Wide Service Flow




                 14
    Develop Future Service Flow For Service Area




Blue Dots – Necessary non-value added activities        Simulate patient flow according to waterfall (leveled workload)
Red Dots – Non-value added waste still exists
                                                        in future layout



                                                   15
   Define Future Space Requirement


   •  Determine room types
   •  Determine equipment requirements
   •  Mock up room and space requirements using paper doll and lego




Desired Procedure Suite Layout   16   Desired OR room with equipment
A Few Principles For the Future State


•  Patient and family center
    –  Value stream from patient arrival to patient leave instead of
       departmental focus
•  Minimum patient and provider travel distance
•  Level workload / waterfall schedule
•  Resource allocation based on Takt Time (patient demand)
•  Flexibility in the utilization of the space
•  Standardized patient room
•  Standardized work
•  Visual Management
•  Just In Time delivery


                              17
Tool Used Prior / During the Event
•    Patient Quantity Analysis (PQA)
•    Time study (cycle time, lead time and takt time)
•    Value Stream flows of medicine (maps)
•    Spaghetti Diagrams
•    String exercise (yarn measurements)
•    7 ways (think like 12 year old)
•    Simulation/Modeling (Lego's)
•    Paper doll layout
•    Mock-ups
                        18
Breakthrough Ideas Include But Not Limited To

 •  New oncology department combines inpatient, outpatient and
    decentralized pharmacy; provide one piece patient flow and utilize
    the resources more efficiently

 •  Expandable and contract-able one stream Emergency layout allows
    to utilize the space and resources based on patient demand

 •  Clinical Decision Unit, adjacent to ED, decongests emergency flow
    and prevent unnecessary inpatient admissions

 •  Anesthetic Care Unit, combined with pre and post anesthetic care
    units, improves patient flow and prevent the admissions from PICU
    and short stay inpatient admissions
                              19
Breakthrough Ideas Include But Not Limited To
•  Standardized universal patient rooms are multi-function, and easy to
   convert for special needs if required. All patient rooms are featured
   with three zones (patient, family and staff care)

•  High Dependency Unit (HDU) in Birthing unit minimizes patient
   transfers

•  Just in time delivery system
    –  dumb waiter dedicated to pharmacy and transfusion medicine
    –  Point of care testing
    –  Decentralized radiology for the department with high patient
       volume but short LT ie. Orthopedics OP

•  Interventional Radiology embedded in surgical suites
                              20
 2nd Chapter of Applying Lean In C&W Site Redevelopment Project

Room Mock Up Workshop – From Dream to Reality
 •  The room sizes in New Acute Care Center were initially determined
    by new Canadian Standards in the first draft of the functional
    program/clinical specification

 •  At the 3P Events teams used paper dolls to come up with room and
    floor layouts based on how they wanted to provide care to patients
    in the future (Desirable), some rooms were taped out on the floor
    with a desired room layout.

 •  Since then the teams have been using a combination of the 3P
    rooms sizes and the Canadian Standards.

 •  Many rooms have been reduced in size

                              21
Understand The Needs Before Decide
What and Where to Cut
•  Objectives of mock up
   –  To determine an appropriate room size(s) that allow the care
      team to provide optimal patient and family care in the most
      efficient way.
•  Types of Rooms
   –    NICU
   –    PICU
   –    Inpatient Room
   –    Emergency Exam Room / Clinical Decision Unit
   –    OBOR, Labor Delivery Room and High Dependency Unit
   –    Physiotherapy room
   –    Rehab room
   –    Anesthetic Care Room
                            22
Determine Basic Space Needs & Space Needed For

  •    Mock up room built as actual size (1:1 scale)

  •    Mock up room set up – basic set up, extra equipment brought in according to patient care process

  •    Mock up rooms would have 3 zones; patient zone, provider zone and family zone.

  •    Scenarios tested – each team tested major patient care events for example:
        –  admissions & transfers
        –  Procedures, tests, imaging, trauma
        –  Delivery of twins needing resuscitation
        –  Code blue
        –  Allied health services

  •    Scenarios involved large equipment and or large groups of providers/people in the room.

  •    Each scenario was reviewed for what worked and what didn’t. What would we have to do to
       make it work (change room layout, orientation, size).


                                              23
Teams In Action
  PICU       Inpatient & Oncology   Elevator




 Emergency          NICU              Birthing




                   24
Outcomes Of Mock Ups
q  Staff Engagement
    –  Each team had 15-20 people participated in the event
    –  Sparking interest from other groups/areas to do mock ups


q  Understanding
    q  What is needed vs. what we think we need
    q  Bigger does not automatically equal to better when comes to the patient care


q  Able to articulate:
    –  Issues with each room size trialed, by scenario
    –  Rational for enlarging room
    –  Critical distances/space needed from one object to another
    –  Standard equipment needed in the room, other equipment the room needs to
       accommodate.
    –  Dimensions for the room

                                     25
3rd Chapter of Applying Lean In C&W Site Redevelopment Project


                   Integrated Facility Design
•  What is IFD?
   –  A systematic design approach that embraces principles of lean thinking and
      integrates the expertise of all stakeholders in a simultaneous way using data to
      increase value

   –  Three stages of IFD
        •  Evaluation and Planning Stage
        •  Design and Development Stage
             1.    Project Management and Governance Phase
             2.    Conceptual Design Phase
             3.    Functional Design Phase
             4.    Detailed Design Phase
        •  Delivery and Implementation Stage
             1.    Work Design – Process Standard Work and Reliable Methods
             2.    Leader Standard Work
             3.    Daily Management System and Daily Accountability
             4.    Visual Management



                                         26
     3rd Chapter of Applying Lean In C&W Site Redevelopment Project


                                  IFD Three Groups
•  Leader Sponsor Group:
       –    Ultimate accountable for the building and system transformation
       –    Define project expectations
       –    Develop project goals and metrics
       –    Hold all participants, teams, organization accountable
       –    Own the project


•  Core Team
       –    Decision making team for the design
       –    Establish the principles and clarify assumptions that guide design action
       –    Participate in the development process from beginning to end
       –    Act as a steward of the lean principles and assure organizational alignment as decisions are made


•      IFD event Team
       –    Provide consultation and input to the IFD




                                                  27
3rd Chapter of Applying Lean In C&W Site Redevelopment Project


                         Transition to IFD
Reasons
•  Many breakthrough ideas have been generated through 3P
   workshops and room mock up event but many of them have not
   been investigated and tested

•  The organization is continuing on Lean imPROVE journey but these
   improve activities are not integrated with the project Lean activities

•  The ownership of the project
    –  What is in and what is out
    –  Who should be responsible for the building design concepts
    –  Who should be responsible for the implementation



                                   28
IFD Sessions


                     Setting up
                    initial layout
                         from
                      indicative
                    design prior
                    to IFD week




               29
Panoramic View of Warehouse set up




                     30
Emergency Reception   31
Front of building at Emergency
                                 32
     Testing Lines of Sight




33
Conducting tours for feedback




                                34
     Redesigning the layout after
        feedback from tours




35
Lessons from IFD Process


•  From perceptions based on a drawing to the reality of a
   floor layout
•  Teams will morph from a departmental focus to an inter-
   departmental focus to a patient focus
•  All team members must have an equal voice in the
   planning
•  Sufficient time is needed for staff tours to understand the
   layout and give feedback
•  The Core Team owns the continuity from one session to
   the next
•  Wear gloves and comfortable shoes
                          36
Things to know before you start

•  Lean design is the most effective when the organization has had a
   lean management system in place for several years

•  Organization leaders must champion the process
•  Requires more up-front planning time than a traditional design
   approach

•  Requires ability to collect and analyse large amounts of data

•  Designers/architect team must be on all events and function as a
   team player instead of information collector

•  Requires a large dedicated space where mock-ups can be built

                              37
Lean Design and Public Private Partnerships (P3)

•  Lean design must be built into P3 procurement process path
    –  More time required for planning


•  Many P3 processes require an Indicative Design as part of the RFP
   documents.

•  Bidders often submit a design that is different than the Indicative
   Design


•  Contract language will have to be clear about maintaining lean flows
   in the RFP design submissions



                                   38

								
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