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Lean-Led Hospital Design: Creating the Efficient Hospital of the Future
By Naida Grunden and Charles Hagood

Hospitals across the country are adopting Lean to improve their processes. Can we create a hospital environment that continuously improves, too?

Lean-Led Hospital Design describes how, from the earliest possible concept phase, Lean ideas and processes can improve the efficiency of hospital design, and support better and better processes.

A must-read for any hospital leader or staff member involved in hospital expansion or building, as well as architects, engineers and construction managers.

As new legislation encourages hospitals to compete on quality, hospitals must find new ways to provide consistently efficient and excellent care to every patient—at greatly reduced cost.

Fortunately, one approach is showing promise in improving quality and reducing cost: Toyota-based Lean principles of respect, continuous improvement and waste reduction.

If Lean is starting to change how hospitals are run, it is also starting to change how they are built.

Order Lead-Led Hospital Design through Amazon.com

Foreword

Form Follows Function: Designing the New Healthcare Delivery System

Never in U.S. history has the subject of healthcare costs been so visible or so contentious. While few Americans can truly appreciate what $2.6 trillion dollars or 18% of the GDP really means, more and more perceive the double-digit increases in premiums and their attendant social costs. Stop for a moment to consider how much money $2.6 trillion represents: spending at a rate of $1000 every 5 seconds, it would take 412 years to consume. Not only does the rising cost of health care deprive working Americans of wage increases and the associated social mobility that once was the American dream, it also has driven unacceptable social tradeoffs. School and library closings in local communities are attributed directly and appropriately to rising healthcare costs. While these impacts are real and increasingly recognized, another variable in the healthcare cost equation-the value of the services rendered- should command at least equal attention. Most Americans might pay more for health care if assured of associated value and, increasingly, a demand for greater value is driving a focus on quality that actually should make health care cost less.

Value in the U.S. healthcare system has been diluted by visible waste like over-utilization, lack of price transparency, and failures both in delivery of care and care transitions. Estimates suggest as much as half of all healthcare spending brings little or no value to patients. Over the last decade, and long before the recent debate over the Patient Protection and Affordable Care Act, a series of pioneers embarked on a precarious journey to transform the delivery system using principles borrowed from other, more reliable American industries. The application of these improvement principles has brought remarkable benefits and lower costs to medical care. The concepts are empirically simple. High-performance health care requires continuous improvement. Continuous improvement requires continuous learning. Continuous learning means identifying and solving problems in the course of work. Solving problems requires disciplined skills and a common language for communicating new learning.

Surprisingly, these rational and inarguable reforms, cloaked in the guise of work redesigns and applied at the point of care, have not been widely embraced or adopted, leading to islands of excellence, amid a sea of prolific opportunities for improvement. Most of this success has eluded the medical literature as medical scholars debate the merits and legitimacy of the science of continuous quality improvement. This intransigence and skepticism has led to insufficient and ineffective communication of these lessons to the medical community as a whole.

These stories- many of them personal sagas- are both compelling and inspirational in conveying what is humanly possible through disciplined problem solving. The new knowledge is sowing seeds of transformation in American healthcare. Naida Grunden, a consummate storyteller, has faithfully and reliably recounted the pioneering journeys of the agents behind these changes. In a previous volume titled, The Pittsburgh Way to Efficient Healthcare, Grunden chronicled a regional Lean effort in southwestern Pennsylvania that aimed to provide patients with only the care they need, at the optimum time, in the most appropriate setting and with the highest possible quality. The accounts are at once personal yet highly professional, simultaneously capturing case histories and human emotion. The improvement processes and work redesigns are elegant in their simplicity; they underscore the transformative power of human capital and demonstrate the importance of tapping the knowledge and experience of all healthcare workers in the pursuit of habitual excellence.

On the heels of this important work comes another contribution from Grunden focusing on the importance of both work and space redesign in the healthcare delivery system. In Lean-Led Hospital Design she and coauthor Charles Hagood illustrate why the application of Lean thinking to the design of healthcare facilities is a critical complement to delivery-system redesign. Their work brings new meaning to the 19th century American architect Louis Sullivan’s heuristic that form must follow function. Just as Sullivan applied this thinking to skyscrapers, Grunden and Hagood describe the critical reasons for permitting function to govern structure in the design of hospitals and clinics. In this natural extension of Grunden’s decade-long study of applications of Lean principles to healthcare delivery, she and Hagood show that transformation of health care and perfection of its processes often requires transformation of the space in which care is given. They guide us through the ways Lean is contributing to both.

To those of us who aspire to better, higher quality health care, the authors also create innovative music to accompany and advance the cause of defect-free delivery. Even as we have applied Lean principles to medical practice as a means of improving the care we deliver, we often have been constrained by the walls and fixtures in the spaces where we work. That work redesign and elimination of waste now informs space redesign is a truly hopeful sign that our first principles are taking hold.

Wonderful examples abound throughout this book and the underlying Lean concepts are articulated in ways both highly readable and readily absorbed. Some of the most telling examples come in the attention given to waiting areas and lobbies, which for all their modern splendor, sentence patients and families to countless wasted hours and offer grand, if mute testimony to healthcare’s yawning inefficiency. What if patients never waited? What savings could be realized in building costs if healthcare facilities didn’t require these space-hogging rooms? Grunden and Hagood offer ways to supplant endless waits. They give us ideas about work redesign and complementary space redesign that are the essential ingredients for that seemingly elusive state of patient-centeredness in health care.

The book is a must read for all healthcare CEOs and board members whose hospitals and clinics are contemplating building campaigns. Before borrowing for construction, these executives should pledge adherence to the brilliant, to-the-point concepts the book describes. These ideas are the moral equivalent of the legal debt covenants bond issues require. No project should be considered “shovel ready” without embracing and applying them.

Richard P. Shannon, MD
Chair, Department of Medicine, Hospital of the University of Pennsylvania
and Frank Wister Thomas Professor of Medicine at the University of
Pennsylvania’s Perelman School of Medicine

Read more about the Authors

Lean-led Hospital Design: Creating the Efficient Hospital of the Future

Naida L. Grunden

A professional writer for over 20 years, Naida has spent the past decade documenting the increasing acceptance of Toyota-based processes (lean) in health care. Her book, The Pittsburgh Way to Efficient Healthcare, captured the seminal work of the Pittsburgh Regional Health Initiative (PRHI), during the introduction of lean in competing hospitals across Southwestern Pennsylvania. She received the American College of Clinical Engineering Challenge Award for her documentation of lean in healthcare.

Naida continues to write, teach and speak nationally and internationally on the topic of Toyota-based principles in health care. She also shares an interest in applying aviation safety and reliability concepts to healthcare.

Naida holds a BA in English from California State University, East Bay, and a California secondary English teaching credential from California State University, San Francisco.

Charles V. Hagood, MBA

Charles is the Founder and President of Healthcare Performance Partners, Inc., a Nashville,Tennessee based Lean Healthcare Consulting firm, which works with the largest for-profit and not for profit hospital systems in the USA. He was also the cofounder and former Managing Principal of The Access Group, LLC , an international manufacturing services and lean enterprise consulting firm whose clients included such companies as GE, Tyco, Cessna, and Ford plus many other automotive, aerospace, and consumer goods manufacturers. He is the creator and editor of the popular LeanHealthcareExchange.com site and founding faculty member of the Belmont University Lean Healthcare Certificate Program.

Charles received his MBA from the Belmont University Massey School of Business in Nashville, Tennessee. Charles is also an adjunct faculty member of the Massey School of Business.

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What people are saying about the book...

“Leading Lean hospitals have learned they need more than ongoing continuous process improvements. Given the chance to build new or expanded facilities and space is a unique opportunity to build in efficiency and patient-centered care from the start. Lean-Led Hospital Design is a fantastic book that shows the reader exactly how to incorporate process design with space design in a collaborative and iterative manner. The vivid examples shared by Naida Grunden and Charles Hagood bring these principles and practices to life. This book will help your organization immensely, whether you are just starting to plan for a new facility or whether you are ready to move in.”

--Mark Graban
Author, Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, 2nd Edition and Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvement

“There are many books on Lean management, but this one really sets itself apart in its clarity and readability. Grunden and Hagood offer a thorough discussion of Lean management techniques in building design. They share real-life stories of healthcare leaders and design teams who took the time to analyze their processes and ultimately achieve incredible project and operational savings through facility design. It’s written in a compelling tone (once you start, you’ll keep reading) providing a clear and actionable path to improved design.”

--Margaret F. Schulte, DBA
Healthcare Consultant
Author of Healthcare Delivery in the USA

“Naida Grunden, author of The Pittsburgh Way, and Charles Hagood have nailed an important oversight in Lean and other industrial engineering applications in health care. Too little attention is focused on the role of the environment and physical plant in making exceptional performance possible. Would a world-class symphony perform in a substandard hall with poor acoustics, uncomfortable seats, audible distractions and visual impediments? Excellent case studies demonstrate how health facilities can be designed to advance safety, clinical quality and efficiency. This book argues effectively that performance excellence must be aligned with a supportive physical environment.”

--Karen Wolk Feinstein
President, Jewish Healthcare Foundation of Pittsburgh
Founding co-Chair of the Pittsburgh Regional Health Initiative

"Lean techniques and tools have been transformative in our organization as a means of systematically analyzing processes and office design to eliminate waste. However, the beauty of Lean principles is that the goal is not simply to eliminate waste or increase efficiency but to ensure that change is always patient centered and driven by the front-line workers who interact with these patients every day. Lean principles help us to keep our patients at front and center whenever we are contemplating changes. In Grunden and Hagood’s Lean-Led Hospital Design, they write with great clarity and wisdom about how lean principles can be used to create the ideal Hospital of the future."

--Eileen Boyle, MD
Executive Director
East Liberty Family Health Care Center
Pittsburgh, PA

“Grunden and Hagood have produced an authoritative, compelling argument for adopting the principles of lean management integrated through all aspects of hospital management from architectural design, construction through delivery of clinical care. In several examples they document the gains to be enjoyed in more functional design, construction cost savings, operational efficiencies, and more satisfying work conditions for healthcare professionals, and – most important – for the safety, satisfaction, and improved outcomes for patients. The unifying vision for building design and healthcare operation is ‘what is best for the patient.’”

--Robert W. Mason
Managing Partner
CC-M Productions, Washington, DC

“Lean-Led Hospital Design is a work we’ve all been waiting for. The authors do a tremendous job consolidating this relatively new body of knowledge into a practical, applicable application that will impact millions of people - enhancing value delivery by removing non-value added waste from the patient experience.”

--Mike Orzen, President
Mike Orzen & Associates, Inc
Coauthor, Lean IT: Enabling & Sustaining Your Lean Transformation

”High quality care and patient safety are requisites of the health care delivery system. This book is a must for every Lean practitioner with its practical real-time examples of facility improvement that engage frontline staff to remove waste and improve outcomes.”

--Debra N. Thompson, PhD, RN
Principal, Debra N. Thompson, LLC
Adjunct Faculty, University of Pittsburgh, School of Nursing

“Naida Grunden and Charles Hagood have produced a miraculous book integrating smarter and continually improvement management and architectural design. Just practicing the new management which dates back to last mid-century Japan has helped several hundred American hospitals cut costs by 50 percent, get rid of hospital-acquired infections and drastically reduce medication and medical errors saving untold lives. Constructing hospitals with the input of knowledgeable managers, doctors and nurses, who are themselves continually learning, hopefully is the key to solving America’s hospital and care delivery crisis. Gruden and Hagood have produced the next leap forward in consciousness and improvement.”

--Clare Crawford-Mason
Producer, NBC White paper, If Japan Can, Why Can’t We?
PBS Documentary, Good News: How Hospitals Health Themselves
Co-Author, The Nun and the Bureaucrat, How they Found an Unlikely Cure for America’s Sick Hospitals

“This book by Naida Grunden and Charles Hagood speaks with engaging clarity about how Lean can and should be used as the guiding philosophy for designing hospitals. One compelling feature is its systems perspective that is sensitive to the interrelated roles of people, processes, leadership, and culture in making Lean work. Another is its emphasis on actionable understanding through a great selection of concrete examples, case studies, images, and insights from experienced practitioners. I cannot think of a better primer on lean-led hospital design.”

--Rangaraj Ramanujam
Associate Professor of Management
Owen Graduate School of Management
Vanderbilt University Order

"Hagood and Grunden have engaged one of the most complex and important subjects facing our great nation. This generations place in American history is taking shape and in no small part will be valued on how we responded to the health care cost crisis. This book provides useful insight as to how we can design care that fulfills its obligation "to do no harm" and yet provide it in a cost effective manner. "

--John Bardis
Chairman, President and Chief Executive Officer
MedAssets

“While there are may be many faces of lean, including process design and facility design, these many faces share one expression – no outcome, no income. Grunden and Hagood have done it! Their latest book points the way, in everyday language, as to how we can achieve an improvement in the quality and outcome of care and save money and reduce error at the same time. This book is a guide for survival under an era of accountability and will drive the ‘no outcome, no income’ agenda deep into the second decade of the 21st century.”

--David B. Nash, MD, MBA
Dean, Jefferson School of Population Health
Thomas Jefferson University

"Tens of billions of dollars are being spent on construction of new healthcare facilities in the U.S. today. Before spending another dime, healthcare executives should read this book and learn how it’s possible to take as much as 40% of the building cost out before a shovel ever goes in the ground. This result has now been proven over and over by many healthcare organizations on the lean transformation journey. As a bonus, but even more importantly, we can improve staff satisfaction and clinical quality at the same time as the cost goes down. Grunden and Hagood beautifully document these outcomes by the use of real case studies in addition to their own extensive experience as careful observers of Lean healthcare."

--John Toussaint, MD
Founder and President of the ThedaCare Center for Healthcare Value
Author of On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry

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