part 1: lean clinical workplace design

Lean Clinical Workplace Design Part I: A Professional Retrospective Leveraging the integration of Evidence Based Design, Design Thinking and Process Efficiency to drive a new standard for the development of architectural workplace solutions that improve the quality of life for healthcare professionals and their patients worldwide.

A White Paper Written by: Henry J. Rahn AIA Associate, DBIA, IDSA, M.Arch June 2014

Lean Critical Workplace Design A White Paper Written By: Henry J. Rahn, AIAS, DBIA, IDSA, Masters of Architecture June 2014

Table of Contents

I. Introduction

II. What is Lean Clinical Workplace Design?

III. Concept Development & Professional Experiences

A. CIBA-Corning Diagnostics

B. ValuMetrix Consulting (Johnson & Johnson Ortho-Clinical Diagnostics)

C. RAHN Design Research

D. Evidence Based Design

IV. Implications & Conclusion

V. About the Author

VI. Bibliography


I. Introduction This is the first of series of white papers aimed at tracing the development path of Lean Clinical

Workplace Design as it evolved in the professional work, experiences and accomplishments of

the author over the past two decades. Ervin Laszlo’s book A System’s View of the World

served as the spark for the author’s quest for understanding how people ‘do things’ or perform

tasks and the processes they develop and use to accomplish a “value set”.

This three part series of white papers is organized as follows:

• Part I: A Professional Retrospective - Chronicles the origin of the Lean Clinical

Workplace Design concept for the author as well as the critical professional projects and

outcomes demonstrating the viability, usability and business success that resulted from

merging evidence based design, design thinking and lean process efficiency.

• Part II: Clinical Process Efficiency Case Studies - Details the process and outcomes

across five healthcare organizations. More specifically, this paper provides in-depth

analysis and recommendations based on engagements with Johnson & Johnson’s

ValuMetrix L6S consulting service, clinical process efficiency consulting delivered by

Rahn Design Associates, and process research performed by Masimo, Incorporated.

The case studies highlight specific qualitative findings such as significant increased

process efficiency reducing the FTEs required resulting in part from spatial layouts

sympathetic to workflow improvements, as well as quantitative findings such as 12% of

a department’s square footage driving 80% of the revenues.

• Part III: Current Methodologies & Thought Leaders – Highlights the work of current

and emerging leaders across the three distinct but merging disciplines of evidence

based design, design thinking and lean process efficiency.

This is a living document that chronicles the development the author’s thinking and the practical

application and advancement of his unique approach to workplace design in healthcare

environments. The work represented here serves as a basis for the ongoing pursuit to build

highly predictive and productive operations through the design and building of integrated

programs and circulations defining space, light, and layout in healthcare workspaces.


II. What is Lean Clinical Workplace Design?

Current EBD + Design Thinking + Lean Process Efficiency =

Lean Clinical Workplace Design Today’s field of architectural healthcare is loosely organized into three methodologies for mining

organizational and spatial data, determining process efficiency and extracting medical efficacy

and patient wellness information from existing healthcare systems:

• Evidenced Based Design (EBD)

• Design Thinking

• Lean Process Efficiency

This paper explores the premise of merging these three methodologies to create Lean Clinical Workplace Design, a methodology and integrated approach with the prospect of improved

results in financial, operative, and brand ROI.

PRINCIPLE CONCEPT Leveraging the integration of Evidence Based Design, Design Thinking and Process Efficiency to drive a new standard for the development of architectural workplace solutions that improve the quality of life for healthcare professionals and their patients worldwide.

The work discussed in this paper will show how the value of process efficiency + quantitative

Evidence Based Design (EBD) can be integrated with the qualitative value of design thinking +

qualitative Evidence Based Design (EBD) to enable a comprehensive, multi-hierarchy

perspective and high-value event discovery for clinical workplaces found within healthcare

facilities. This approach is presented as potentially a new standard to advance the design and

development of architectural workplace solutions that improve the quality of life for healthcare

professional and their patients worldwide.


III. Concept Development & Professional Experiences A. CIBA-Corning Diagnostics Research

Studying Industrial Design at the prestigious University of Cincinnati’s Design, Art, Architecture

and Planning (DAAP) was a daunting challenge. A rigorous five year curriculum started with

approximately 60 students and graduated only 25. DAAP embraced a culture to explore and

develop the very depths of your intellectual and intuitive capabilities. It was in this environment

that I read Ervin Laszlo’s book A System’s View of the World as part of my senior curriculum.

Laszlo’s systems philosophy offered a kernel of inspiration and placed me in uncharted waters,

“where danger and opportunity collide and create a fertile plane for innovative growth.” Laszlo

unlocked the concept that process, i.e., the steps we use to accomplish a task, such as baking a

cake, is the glue that enables us to deliver practical creativity to market. From a designer’s

perspective, you need all of the human “touch points” identified from space to appliances to

baking pans and cups. Similarly, an architect could consider the spatial layout and how it best

supports room to room process or steps required to not only bake a cake, but all the individual

tasks, and destination points required to cook any meal. Additionally, the architect may wish to

consider how walls would create space and promote flow from one room-task-destination point

to another.

As a professional industrial designer and usability researcher, I translated this critical concept

into the study of how people ‘do things’ or perform tasks and the processes they develop and

use to accomplish a “value set”. I did this by applying human factors observational research

skills in the clinical space to identify the processes developed by physicians and scientist to

diagnose and treat patients in that space.

The approach I developed translates an instrument and the operative spatial layout it requires to

complete a task into practical measures. The charts on the following page document the output

of my approach. This methodology first observes a diagnostic instrument’s “ease of use” with

how much time it took a laboratory technician to complete a singular task and to complete the

process. Next, I observed and measured the physical path an individual would take going to and

from each destination point as a result I could determine the efficacy of the spatial layout as well

as the user interface (or user experience) of this particular clinical process.


This attention to detail (L6S thinking) offers a keen insight into the occupant’s process and how

technology was configured so that unskilled technicians could use diagnostic instruments to

derive a specific and repeatable result. Further, this level of detail enables multiple evaluations

of the spatial layout and how it affects the process and productivity measures.

This methodology was fully embraced by CIBA-Corning Diagnostics for both marketing and

usability research and was rolled out in a two-phase international study. The first phase included

the construction and completion of a comprehensive workflow analysis of hospital diagnostic

testing laboratories in the major metropolitan areas of the US and Germany. The analysis

documented the spatial layout, equipment layout within that space, and the workstation location

of the lab technicians with the flow between destination points. The second phase of the work

included the evaluation of the layout with the intent of reorganizing workstations and spatial

layouts to improve management metrics like, “time to result”.



B. ValuMetrix Consulting, Johnson & Johnson Ortho-Clinical Diagnostics

Moving forward ten years, Don Mooney a marketing executive from CIBA-Corning’s Immuno-

Diagnostics (CCD) Division assumed the position Sr. VP of Marketing with Johnson &

Johnson’s Ortho-Clinical Diagnostic division. A key to his advancement was an understanding

the consultative relationship with his clients and the value added service of workflow analysis in

the testing laboratory; a decision later supported with the 2006 ISOR&MS white paper,

“Modeling Patient Flows Through the Healthcare System”19. In an evolving market of automation

and robotic systems in testing laboratories, Don recognized the value of CIBA-Corning’s

research methodology and brought Rahn Design Associates (RDA) in to assist Jim Ellis,

another CCD executive, with defining ValuMetrix, a process efficiency and “activity based

management” consulting service for Johnson & Johnson’s Ortho Clinical Diagnostics, see charts

below and Appendix C (MGH “Arc Light” presentation)

At the core of ValuMetrix’s service offerings, is a multi-disciplined team tasked with defining a

comprehensive solution for hospital administration to reach their targeted management metrics.

RDA designed a workflow analysis and spatial reorganization program that served as one of the

key elements of the service. In addition to expertise in determining the efficacy of the spatial

layout based on user actions and interactions, RDA brought an architectural perspective to the

work with ValuMetrix.

After the ValuMetrix team successfully demonstrated the validity of the service offering in

several hospitals, Lean Thinking3 and Six Sigma process efficiency techniques were added with

“value stream mapping”3, see below. These service solutions formed Lean Six Sigma (L6S)4, a

new segment of the consulting service. The ValuMetrix and RDA partnership went on to

develop more than fifteen major hospital testing laboratories’ workflow and space planning.


III. Concept Development & Professional Experiences C. RAHN Design Associates, Inc. (RDA)

After the 2001 recession, the healthcare marketplace started to experience a fracturing of its

traditional hospital centric strategy. A new approach focused on patient access to specialty

practices began to emerge. To support the physician requirement for stronger balance sheets

and profit margins in an increasingly difficult reimbursement economic climate, practices turned

to process efficiency. Leveraging RDA’s success with ValuMetrix, RDA introduced ValuLine

Consulting services, see charts below.


ValuLine Consulting is a multi-disciplined, lean process efficiency service identifying muda, a

Japanese term for waste and a key to lean thinking, an efficiency process developed by James

Womack and Daniel Jones for Toyota and embraced by GE.

The team consists of four primary disciplines, workflow analyst, technology analyst, architectural

analyst and business analyst.

Workflow Analyst - Provides most of the observational and quantitative research of the

site’s FTEs as they perform their specific skill-sets while circulating through their

workspace accomplishing a value-set. Typically, a hybrid between a human factors

specialist and product designer.

Technology Analyst - Evaluates the technology or product application required to

accomplish a task. Typically this would be someone with a scientific degree and

experience in performing the site’s value-set.


Architectural Analyst - Documents the current built site and works with the workflow

analyst with understanding the use circulation. Typically, an architect with significant

experience in work space design.

Business Analyst - Performs the P&L analysis on the site working directly with the

site’s management to breakdown expenses and how they relate to the specific tasks,

technologies and FTEs required to accomplish the value-set.

Applied here, muda identified waste in specialty healthcare practices’ process of delivering care

to its patients, or in this case the value-set. Through onsite research the team used several

observational and quantitative techniques to define evaluative criteria of existing practices

healthcare delivery processes, the medical devise use, and the spatial layout of the practice’s

location, see chart below and Appendix A (Midmark Inc. Podiatry Specialty Practice workflow

analysis)


RDA synthesizes this information reengineering the workflow of the process and redesigns the

spatial layout of the facility to better support the practices healthcare delivery process.



D. Evidence Based Design in Healthcare Architecture

Another architectural research methodology that developed out of healthcare administration’s

need for a more efficient and informed spatial and programmatic layout is Evidence Based

Design (EBD).

Formalized with their 2009 publication, “Evidence-Based Design for Multiple Building Types”2,

D. Kirk Hamilton, FAIA and David H. Watkins, FAIA, EBD developed a nine (9) step process for

evidence based design (EBD):

1. Establish the Client’s Project Goals

2. List the Practitioner’s Project Goals

3. Identify the One to Three Key Design Issues

4. Convert Key Design Issues into Research Questions


5. Collect Information and Gather Evidence Relevant to the Research Questions

6. Critically Interpret the Evidence

7. Develop Concepts to Achieve Desired Design Outcomes

8. Hypothesize Predicted Outcomes Linked to the Evidence-Based Concepts

9. Select Measures Suited to the Questions Posed by the Hypotheses

As stated in their research, these milestones and action items in Hamilton and Watkins’

process are developed and evaluated by a multidiscipline group of architects, engineers,

interior designers, and a variety of other consultants. The team is tasked with identifying the

evidence required to define specific architectural impact of the client’s program or intra-

program/inter-program relationships. It is additionally their responsibility to define their

evidence sources as well as establish its credibility and value to the project. Finally, one of

the key decisions this team needs to make is when to develop their own research and what

does that look like.


VI. Implications & Conclusion

Current EBD + Design Thinking + Process Efficiency =

Lean Clinical Workplace Design

Why is today’s healthcare executive management embracing “Lean” and “Design Thinking”

solution generating methodologies as successful processes for their current institutional and

organizational problems? Is it symptomatic of the perception that healthcare in the United

States is “broken”? Or methodologies that offer insight into the advancement of humanizing the

hospital infirmary image while building process improvement that measures a balance between

performance metrics like “Time of Patient Stay” and “Clinician Satisfaction”. Finally, what is the

value of “evidence” to the healthcare system’s board of directors in evidence based design

(EBD) and can EBD function as a predictor of the constant demand for knowledge growth in

today’s global healthcare society. A simple answer is a measured yes.


An organizational result of the last three decades of meteoric growth in the information

technology sector is the dismantling of vertical silos and the evolution of integrated matrix

management, or cross-discipline teams. This team structure can be witnessed across problem

solving professions both tangible and intangible, product/architecture to intellectual

property/finance. In healthcare architecture, these teams have evolved from EBD to lean centric

in response to healthcare management’s market demand. To add another level of quantitative

vs qualitative balance to this multi-discipline team’s output this paper proposes to introduce

design thinking methodologies to the mix, as seen North York General Hospital in Toronto,

Ontario Canada and SSM DePaul Health Center in Bridgeton, MO.

The synergy in joining the scientific rigor of EBD, the process efficiency of lean and the creative

problem definition and solution generation of design thinking combine to focus on a balanced

outcome that can address intra-organizational relationships, enhanced management

performance metrics, and the humanizing results to clinician and patient workplace well-being.

As the previous documented section of this paper reveals, all three processes have proven

individual track records of providing significant results to healthcare management. The

evolutionary combination of these disciplines and processes derives a logical outcome of a

simple, balanced result addressing the continuum and complexity of an ever changing global

healthcare system and their individual architectural requirements.

To implement these findings of Integrated Evidence Based Design (IEBD) and multi-discipline

applied research teams requires complete buy-in from the client with an understanding of how

the team’s involvement during pre-design, schematic design, and post occupancy evaluation.


Possibly the more crucial informed decision making stage of the architectural process, pre-

design would benefit from the tri-IEBD team research methodology. Starting with assisting with

the executive management client and architect team with the defining the scope of the program

and identifying primary areas of value, the pre-design research team would identify like

healthcare facilities within the client’s healthcare system and build a research project build

around the executive strategy and required value based data.

Design thinking focusing on qualitative observational information, EBD on the current

therapeutic environment data, and process improvement on the clinical protocols of each

department/program. These groups would develop the potential opportunities, like the 12% of

the program’s square footage accounts for 80% of the program’s revenue, and together with

executive management decide which opportunities to pursue and which do not possess the ROI

to integrate into this program. Next the team would work with the project architect to develop the

project specification with the value points integrated.

During the schematic design (SD) phase of the program there would be joint research and

design architect brainstorming session to develop multiple solutions, comparable to the Design

Thinking process. Decision making points would be developed with the insurance that the

concept value would be retained throughout the process.

A management dashboard would be developed as a tool for post occupancy evaluation (POE)

with on-going observational research during the design development (DD) stage of the project.

The integration of the dashboard into the sites information technology as well as establishing an

observational measure would be part of the POE stage of the program.

This integration of design thinking and lean process efficiency into an up-to-date EBD data

base has individually proven positive ROI precedence on the financial, operative, and brand

segments of healthcare systems and would advance the application of Lean Clinical Workplace

Design.


V. About the Author Henry J. Rahn, AIAS, DBIA, IDSA, Masters of Architecture

Within the new millennium, society recognizes that the working population spends more than half of their lives interacting in and with designed space. Whether physical, cognitive or perceptual our reality is being shaped by an ever expanding global cultural and intellectual awareness. As a designer and emerging architect, my personal and professional life mission has been and is dedicated to creating inspiring workplaces and innovative products that motivate people to excel within the boundaries of our ever fragile earth.

Henry J. Rahn

Henry Rahn is an experienced, award-winning industrial designer, UX researcher, and emerging

architect with expertise in observing, documenting and building evidence based solutions. His

analysis and design solutions provide high impact, measurable and high-value content for

globally innovative medical devices, industrial products, user protocols and professional work

spaces.

Henry received a master’s degree in architecture from the University of Colorado College of

Architecture and Planning in May 2014. He is a member of Tau Sigma Delta, the Architecture

Honor Society. Additionally, he was awarded 1st place for the 2013 AIA College of Fellows

Student Award. His designs were recognized as winner of the 2014 Young Architect AG for

Unbuilt Architecture and Honorable Mention for the 2014 Young Architect AG Build Architecture.

Henry’s professional work as an industrial designer in medical devices was recognized in 1990

as “Design of the Decade” by the Industrial Design Society of American. He also won Gold level

recognition at the Hannover Fair iF in Germany. Henry holds a Bachelor of Science degree in

Industrial Design from the University of Cincinnati.

For over 20 years, Henry has served as leader of RAHN Design Associates, a research and

consulting firm he founded. Additionally, he has served in various corporate design leadership

positions that have allowed him to demonstrate his commitment to improving the human

experience in healthcare.


VI. Bibliography

BOOKS

1. Change by Design, Tim Brown, HarperCollins, 2009

2. Evidence Based Design for Multiple Building Types, D. Kirk Hamilton, FAIA & David H. Watkins, FAIA, John Wiley & Sons, Inc., 2009

3. Lean Thinking: Banish Waste and Create Wealth in Your Corporation, James P. Womack, & Daniel T. Jones, Simon & Schuster, 1996

4. The Lean Six Sigma Guide to Doing More with Less, Mark O. George, John Wiley & Sons, 2010

5. The Systems View of the World, Ervin Laszlo, George Braziller, Inc., 1972 ARTICLES

6. “Design Thinking”, Tim Brown, Harvard Business Review, June 2008, pp. 84-92

7. “The IDEO Cure”, Susan S. Szenasy, METROPOLIS, October 2002, pp. 2-9

8. “Applying Different Processes for Evidence-Based Design”, Jaynelle F. Stichler, HERD Journal, November 15, 2013

9. “A Framework for Evaluating Evidence in Evidence-Based Design”, Debajyoti Pati, PhD, HERD volume 4, number 3, pp. 50-71, 2011

10. “The Impact & Application of Evidence-Based Design”, Douglas V. Elting, AIA, axiom 411 blog, 1999

11. “The Future of Evidence-Based Design”, David Whitemyer, Perspective (IIDA Journal) Spring 2010, pp. 9-14

12. “Evidence-Based Design: The Deeper Meaning to Sustainability, Building Performance, and Everything Else”, Zach Mortice, AIArchitect This Week, June 26, 2009

13. “Checking the Pulse of Healthcare Architecture”, Sara Fernandez Cendon, AIArchiect, February 18, 2011.

14. “Lean Design: Doing More with Less”, Gwynneth Anderson, Healthcare Design, January 7, 2014

15. “Lean Design: What’s it all About?”, Jeffrey Stouffer AIA, Healthcare Design, April 9, 2013

16. “Practice Evolution in the New Healthcare World”, Jeffrey Stouffer AIA, Healthcare Design, January 9, 2014

17. “Using Lean Design to Overcome 8 Deadly Wastes”, Anne DiNardo, Healthcare Design, December 6, 2013


18. “Therapeutic Environments”, Ronald Smith, AIA, Nicholas Watkins, PhD, Therapeutic Environments Forum, AIA Academy of Architecture for Health, June 18, 2010

WHITE PAPERS

19. “Capital as a transformation tool, Design as a change tool”, Clifford Harvey, Health Capital Investment Branch, Ontario Ministry of Health and Long-Term Care, UIA/PHG 2013 Annual Healthcare Forum + GUPHA Meeting, September 24-28, 2013

20. “Modeling Patient Flows Through the Healthcare System”, R. Hall, D. Belson, P. Murali and M. Dessouky, from, Patient Flow: Reducing Delay in Healthcare Delivery, International Series Operations Research & Management Science, Volume 91, 2006

WEBSITES http://www.healthdesign.org/

https://www.herdjournal.com/

http://www.healtharchitects.org/


http://www.healthdesign.org/

https://www.herdjournal.com/

http://www.healtharchitects.org/