CASE STUDY 1: OPTIMIZING FLOW AND LAYOUT FOR A NEW FACILITY

·  When a healthcare organization has committed to constructing a new building, it represents a unique opportunity to design the physical layout of a facility to be integrated with and facilitate process efficiencies (see Figure 1). The process of Lean/TPS facility design and layout is a new and exciting discipline, and is able to leverage Lean/TPS tools and methods. ·  Architects are customarily compensated based on the number of square feet designed, so there is an incentive to maximize the designed space.·  Staff are asked to speculate on future growth, and this future space is built into the new plan.·  With the current “use it or loose it” facility management philosophy, departments make use of this future space immediately.·  Wastes (such as motion, transportation, excess inventory, etc…) result, and when the space is needed in the future, it is not available, and even more new construction is required.

·  Design a workplace that is good for patients, staff, flexibility, technological advances, and growth·  Integrate staff and physician expertise and process knowledge earlier and much more thoroughly than is done in architectural design processes·  Increase the percentage of space that is value-added, and decrease the overall square footage when it is not needed·  Design space that is conducive to visual management, safety, experimentation, and flow·  Facilitate the full use of team creativity to design multiple future-state design alternatives·  Demonstrate clear “before” and “after” design and celebrate the teams success and ownership of the new design

•  Use low-tech, cheap, and engaging “paper Kaizen” approach  (see Figure 3)•  Need to “Lean the process out before you move”…otherwise, you are moving your old problems into a new building!•  This process will most likely either eliminate, delay, or minimize the cost of the proposed new construction or remodeling (see Figure 4).•  Increasingly collaborative and aligned relationships and incentives with A&E firms, Lean Experts, and hospital Customers need to be fostered.•  The earlier that Lean design principles are integrated, the less expensive these principles will be to include•  When possible, don’t bolt anything down!  Allows for future experimentation and process improvement•  Avoid using cabinet doors whenever possible!•  Make “hard” and “soft” spaces!•  Integrate staff in the development of a more effective, safe, and efficient process before beginning the construction•  Focus on all levels within the hospital (within, between, overall)

Case 1:  Lean Lab Design Project (major remodeling)

• Customer validated 7:1 Return on Investment (ROI) ($1,240,000 savings) at project completion
• Reduced lab expansion from 23,238 to 7,489 square feet (68% reduction from 15,749 ft2reduction in expansion)
• Accommodated significant growth projections with a much smaller footprint
• Increased staff engagement and ownership of new design
• Additional savings of $3,000 and ongoing savings through inventory stabilization project
• All lab staff trained in Lean, and multiple self-sufficient embedded coaches were developed
• Metrics board and daily “huddles” integrated into daily lab operations
• Project presented to senior hospital leadership, which accepted the proposal

Case 2:   Critical Access Hospital Lean ED Redesign (remodeling): 

• Facilitated a multi-disciplinary team to design an innovating 3 level segmented flow of ED patients.
• This new design will allow approximately 50-75% more patients to be seen within the same footprint.
• The team-based design process also decreased the architectural design cost through reduction of individual staff review sessions and the team driving the initial macro-flow layout

Case 3: Lean Clinic Design project (new construction)

• Decreased clinic space by 7,440 ft2 ($316,200 in savings), as well as accommodating an additional 3,720ft2 due to design reduction (for a total reduction of 11,160 ft2 and $474,300 savings)
• Decreased walking by the following amounts: Patient (25%), Nursing (27.4%), Provider (57.8%), Overall Average (32.1%)

Case 4:  Rural Healthcare Clinic Lean Design Project (new construction)

• Decreased square footage (returned to shell for future growth) by 2,720 ft2, and added an additional 1,477 ft2 of revenue generating space not in the original plan, resulting in $231,200 (+$125,545 cost avoidance by accommodating the new space) for $356,745 in total savings
• Increased revenue of $400,000 per year through new revenue generating areas (Eczema “light box” and optometry department)
• Decreased walking by the following amounts: Patient (15%), Nursing (9%), and Provider (40.8%)

·  Most hospitals in a large non-profit system had on-site laundry facilities, which were aging and in need of replacement.  Instead of further investments in these individual hospital laundry facilities, system leaders saw an opportunity to gain efficiencies through centralizing laundry services in a large off-site industrial laundry facility (and eventually offering services to hospitals and clinics outside of their system).  A total of $10,000,000 was invested in a state-of-the-art facility with no expense spared. From the initial launch of the laundry, shortages of operating room (OR) towels and scrubs were threatening to shut down the OR at the main hospital (the financial engine of most hospitals), and the offsite (laundry processing) and onsite (laundry distribution) managers were not on speaking terms due to animosity and finger pointing resulting from this poor system performance. 

• Eliminate OR scrub and OR Towel outages at the main hospital.
• Re-establish and improve the operational and working relationships of the onsite and offsite laundry managers.
• Dramatically improve reliability of laundry deliveries
• Decrease outage calls to the flagship hospital
• Decrease workload of staff associated with the flow of laundry
• Improve utilization of floor space at both facilities (onsite and offsite)
• Decrease system risk due to offsite laundry (if weather or other event cut off hospital from offsite laundry)

·  Given contentious situation, conducted extensive Nemawashi and Genchi Genbutsu to thoroughly understand the process, breakdowns, opportunities, and interpersonal challenges·  Conducted a Value Stream Mapping event, which created 150 team-derived action items.  Given particularly fractured process, proposed a conceptual future state vision of “pull” and “kanban” to gauge the team’s thoughts, which were extremely positive and thoroughly adopted (essentially a high level “kata” vision to challenge them) (see Figure 2)·  Utilized a “Paper Kaizen” approach to engage staff (see Figure 3)·  Due to critical and time-sensitive nature of the project, expedited project and facilitation of action plan from the norm of approximately 1 year to approximately 2 months·  Changed elevators from 2 cart per ride elevator to a service elevator that could carry 6 or 8 carts at a time (dramatically reducing trips)·  Restocking to a PAR rather than a fixed daily order.  Onsite and offsite laundry operating based on visual Kanban and PAR’s defined by managers and staff·  Predictable delivery schedule for both clean and dirty (return) flow

·  Enabled a close and friendly working relationship between onsite and offsite laundry managers…who became friends and communicated continuously throughout the day!·  Established supermarket based pull system at hospitals and laundry facility  (see Figure 4)·  Decreased outage calls at flagship hospital from 45 to less than 4 calls/day·  Solved pillow return problem, thus avoiding original plan of moving to disposable pillows·  Decreased system risk posed by offsite laundry by establishing safety-stock and rotation system at onsite laundry distribution area·  Decreased Average Total Trip Time from 78 minutes to 66 minutes (15.4% reduction)·  Time per cart decreased from 144 seconds/cart to 120 seconds/cart (16.6% reduction)·  98% of 150 Action Items completed by the end of the main project

• Operating Rooms (OR’s) represent the greatest opportunity for margin and profit impact (positive or negative) of any hospital department, but also represent the greatest expense and risk.
• Between OR cases (same room/same surgeon), the rooms must be turned over, which includes cleaning, restocking, preparation for the next case, pulling the next patient in…. all within a relatively brief period of time.
• Without a well-coordinated process, the turnover time can take too long and waste critical OR time.  This can result in fewer cases being completed in a day and/or increased overtime expenses and frustration of staff and physicians.
• Most OR turnover processes contain infection control, ergonomic, and supply waste opportunities for improvement.
• This case study is a meta-analysis that explores three OR Quick Turn-Over  (QTO) Kaizen events, with the consistent results validating the impact of this methodology (when facilitated properly)

• Decrease OR Turnover Time
• Improve infection control and compliance
• Decrease staff injury risk
• Decrease supply costs
• Improve overall flow and coordination
• Improve staff engagement

·  Conducted 3 day intensive Kaizen events, with a heavy emphasis on real time experimentation and standard work development & refinement·  Pre-work included video version of “current state”·  Focus on orthopedic cases (total hip and knee) as the OR QTO “model line”·  Single-Minute-Exchange-of-Dies (SMED) methodology, developed by Shigeo Shingo, was used to standardize and decrease OR turnover times, primarily focusing on:  (1) Separating internal from external setup operations(2) Converting internal to external setup(3) Standardizing function and(4) Adopting parallel operations.·  Developed standardized turnover process focusing on parallel processes, clear triggers and delineation of duties, visual management, and moving internal to external steps .·  Continually emphasized to staff that this process was not focused on working faster, but on coordination and teamwork around standardized processes, triggers, and never compromising quality or safety.

·  Decrease overall turnover time (“wheels out” of last patient to “wheels in” of next patient from between 40% to 55% (see detailed results below)·  Improved infection control risk through standardized process, decreased dwell-time through new antimicrobial solution, and clearly defined sequencing of steps to ensure infection control compliance·  Decreased staff injury risk through reconfiguration and standardization of case carts (heavy orthopedic trays on top instead of on bottom)·  Improved communication through better utilization of existing technology·  Decreased “open but not used” supply waste through pre-picking into “open”  (green) and “have available” (red) bins.·  Decreased overtime and additional cases added to the schedule.·  Improved staff engagement and ownership of the process to support ongoing development and continuous improvement.