More and more healthcare organisations are applying lean thinking to their projects. This helps to improve flow and eliminate waste. Most importantly, it complements the level of patient-centered care offered within an organisation. Leading healthcare organisations in the UK are further boosting their efforts through the effective use of a collaborative, lean-based design approach.
The North East Transformation System (NETS) is working on a lean design of space project. The ultimate aim is to create an intervention where all stakeholders have a voice in the design process. This includes everyone from the patient to the clinicians who will use the area on a daily basis. This helps to increase the level of understanding regarding the specific needs of the patients, staff and visitors. The philosophy is heavily based on the old Japanese proverb that ‘none of us are as smart as all of us’.
Fully engaged healthcare staff and patients, working passionately towards a common aim, can seamlessly create a platform where breakthrough solutions flourish
Essentially a rapid set of iterations take place over a short period of time. This allows for the dovetailing of ideas where the best parts of each design concept are fused into the best available option for the team and facility in question.
Post-Francis there is much being said about staff engagement, or the lack thereof, it is refreshing to see the excitement which collaborative design can bring to a room. Fully engaged healthcare staff and patients, working passionately towards a common aim, can seamlessly create a platform where breakthrough solutions flourish.
Traditionally the ‘throw it over the wall’ approach is often used. In this instance too many assumptions lead to costly changes further down the project life cycle. More worryingly, obvious things get overlooked. This happens when the ‘obvious things’ are apparent to the people who work in the system on a daily basis. However, they are less obvious, and often dare I say hidden, to those who don’t share a deep understanding of the work that occurs there.
So why does this happen? The traditional design approach is based on a sequential set of activities. Very often this is paper-based. Information is captured from users and providers. Key pieces of information get omitted as the design progresses through each step. A lack of joined up thinking results in sub-optimised AutoCAD drawings. These focus too much on form and don’t consider function; such as how the patients will flow through the system or, worse still, how the clinicians will provide superior patient-centered care through the utilisation of effective layouts and environmental surroundings.
There is a greater chance of this happening in organisations where designers and architects are for the most part kept separate in invisible organisational silos. However, let us look at this from an estates point of view. The primary requirement of any architect is a well-defined brief. A common understanding of what is needed, why it is needed and where it is needed goes a long way in forming this brief. Organisational silos must be broken down in order to create an environment where this seamlessly happens. The NETS Lean design of space approach is one big step forward in achieving this. It allows a collaborative team of stakeholders to all work towards a common aim and set of objectives.
With this new approach the team deep dives into a specific area. In this instance it involved working closely with the endoscopy unit at the Queen Elizabeth Hospital in Gateshead. The endoscopy team is very passionate about the work it does. They have been successful yet again in achieving full JAG accreditation. However, they are not happy to rest on their achievements. They want to remain as leaders in their field. And more importantly they have ambitions of co-designing a new flagship endoscopy unit. This will allow them to continue to share best practices with other endoscopy units throughout England.The team showed a strong commitment to patients. Both patients who participated offered instant feedback on ideas put across by various members. It was very grounding, yet powerful, to hear the patients detailed explanation of their patient experience firsthand.
This process of instant feedback was repeated on many occasions as the team drew on each other’s area of expertise to answer questions right there and then. This is the exact opposite of typical requests for information. These are often raised during the early stages and can initiate a long, drawn-out process where progress is stalled as key parties await feedback.
Intervention
The pilot site intervention kicked off with an overview of key lean concepts. The aim was to keep it brief as the participants would gain a greater appreciation of the seven flows of healthcare and the seven wastes through experiential learning. This pragmatic approach to teaching the key concepts was greatly appreciated by the participants. By the midway point of day two, patients were enthusiastically talking about patient flow, clinician flow and equipment flow to name just a few. Other more experienced participants said that the ‘practical application’ and weaving together of collective experiences was the best way to ensure that knowledge transfer occurred.
Every iteration offered a further opportunity for the participants to experiment and play with both their knowledge and experience as they spiralled upwards towards a common optimum design. It was then time to define the current state. This was supported by pre-work and data analysis carried out prior to the event. Nevertheless, the group relished the opportunity to gain a common understanding of all the processes that supported the complete patient pathway. Again this allowed direct service providers to gain an appreciation of what happened in the back office function and vice versa.
The groups, who by now had been split into three separate teams, set about creating their vision boards. This helped to visually show what each group was attempting to do. It is very true that a picture is more powerful than words, and vision boards take this concept even further. It allowed the teams to come together and share ideas in a non-threatening manner. The end results were all very different. Each group appeared to have different strengths which made it all the more interesting.
Following this the groups started to come up with different concepts for the future design. This was done at a high level and all ideas were encouraged. In the end there were 46 sets of ideas. The challenge was then for the teams to narrow down their ideas. Firstly they looked for duplicates and following this they looked for concepts which were not too dissimilar. This created lots of energy among the teams as they literally poured ideas and explanations onto their design tables. From here the teams had to self select the three designs they felt were most promising.
More and more healthcare organisations are applying lean thinking to their projects. This helps to improve flow and eliminate waste. Most importantly, it complements the level of patient-centered care offered within an organisation
The teams worked feverishly to create larger scale versions of their three designs. They also added in some visual help. The flows they added in provided an extra layer of information. Once each team had completed this there were nine 1:100 2D scaled plans in the room. The teams got to explain their design to the other teams. Both of the teams who had patient involvement also had them give their own unique view on the designs they were involved with. Of course many questions were asked and even a few similarities were noticed at this stage.
It was then time for the participants to vote on the design they felt merited further development. There was one catch - you could not vote for any of your team’s designs. This meant you really had to listen to the concept explanations. This helped the group focus in on three key designs. The task was then to further develop these three designs into something better. To begin with they had to build scaled 3D mock-ups. But, most importantly, due to the iterative nature of the process, they also incorporated key design features from other designs into the final three. This helped to evolve the final designs. The designs all demonstrated streamlined layouts with efficient patient flow. They also incorporated aspects of layout optimisation and effectiveness.
On numerous occasions team members went back to the data wall to gather information on demand for different procedure types. This too helped inform choices such as the number of rooms needed depending on different shift patterns.
By now each team was working on one design each. The three designs all progressed at different rates. It was interesting to see people getting on and just doing it while others took a more procedural approach. Again this created lots of energy in the room as each team kept an eye on the other teams’ progress. The teams were under pressure to meet a deadline. This forced some teams to take a quick and crude approach in the final few minutes.
It was then time to vote again. Keeping the same rules the teams had to vote for the design they felt met the agreed design criteria. A weighted average criteria evaluation scheme was used. This placed aspects such as patient flow ahead of other criteria. All this took place at a high level and led to one final concept being put forward. Again this was self selected by the entire group.
It was then time to take a closer look at the designs. This involved making life size mock-up of patient suites and pods, as well as treatment rooms. It was very interesting to see the differences in designs. This was one of the most powerful aspects of the collaborative design process. All the patient suites looked similar in 2D and even in the scaled 3D models. However, when they were built to full-scale the differences were vast. For example, the largest patient suite was twice as big as the smallest one. Simulations carried out in the various mock-ups allowed for quick changes to be made. And this resulted in even more rapid prototyping and iterations taking place.
The teams were then reshuffled. This increased the rate at which the cross-pollination of ideas were both spread and adopted. The best features of the life-size mock-ups were incorporated back into a new scaled 3D design by each team. Most interestingly, on this occasion at least, the three final table designs were almost identical thanks to the dovetailing of ideas, people and hard work towards a common goal.
Conclusion
The event ended with a presentation covering what had been achieved during the five-day event. Representatives from estates had the opportunity to give their feedback on the process. Similarly the patients gave very positive feedback and thought that it was tremendous being involved in such an innovative initiative. Other service providers said it was exciting to be part of the early design stage and could not wait to get back to tell the rest of their team how it went.
