Leapfrog! - btmteam.net · Leapfrog! finding architecture ... annual ﬁnancial data ﬁle for report periods ended January 1, 2004 to December 31, 2004. ... lab/ECG/PFT/x-ray 3 steps

© 2007 David F. Chambers

Leapfrog!finding architecture to apply Lean

workflow in acute care…and implementing the solution!

– the Sutter Health Prototype Hospital initiative

using lean project definition and delivery

September 2007


why change?

• US healthcare spend represents 16%+ of GDP (virtually two or more times that of any other country in the world!)

• industry produces no tangible goods (value)• industry track record regarding errors and accidents is

notorious: must change!• serious staff shortages plague nearly all US markets• facility costs are skyrocketing• multiple payers creates confusion and additional costs: 31%

of total healthcare dollars spent in US on administrative costs

• source: The New England Journal of Medicine, Volume 349:768-775 August 21, 2003 Number 8 “Costs of Health Care Administration in the United States and Canada” (Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., and David U. Himmelstein, M.D.)

• model is not sustainable- Womack and Jones: “…specialized, large-scale, high-speed, highly efficient production

departments and equipment are the key to inefficiency and uncompetitiveness…”

• source: Natural Capitalism, Chapter 7: Muda, Service and Flow, (Hawken, A. Lovins and L. H. Lovins)


Insanity:… “doing the same thing over and over again and expecting different results!” Albert Einstein (attributed)


how might we solve healthcare differently?

• look at best practices in other industries: what can they tell us?− Demming PDCA cycle (plan-do-check-act) transforms manufacturing

o PDCA becomes basis for CQI implemented in healthcare

− Toyota evolves to Toyota Production System (TPS), key features include:o Kaisen - small perfections to process are cumulative (rapid process

improvement weeks)• Similar to CQI with more rapid performance monitoring

• LAMDA product development cycle (look-ask-model-discuss-act)

o A3 reports capture learning


the opportunities and the challenges of lean

• the danger of CQI (PDCA) and Kaisen in their current state is that they don’t give us the chance to look beyond the process to the reason for the process− if we look at trees and only see trees, we may not see the forest, (the

ecosystem that we need to manage to sustain our lives) and we will only address the needs of the tree, not the balance of life within the ecosystem that makes the forest

• LAMDA promises a different approach for addressing the system (that we might optimize the whole not the pieces)− look at the trees, see the forest (system), ask why the system does

not flourish, model resolutions to respond to the needs of the system, discuss this model with our knowledge holders and build consensus for action, act based on an informed decision


seeing costs

source data: Office of Statewide Health Planning and Development. Data extracted from hospital annual financial data file for report periods ended January 1, 2004 to December 31, 2004. The data were extracted on September 19, 2005.

hospitals in the State of California distribution of direct expenses by natural classification


looking beyond the bed:typical daily patient distribution in a modern medical center:

9%

91%


using our observations to form new questions

• from observations we can determine who we need to ask - define the conversation− how might we change the way care teams are configured to improve

care delivery?

− would those changes lead to reduced need for resources (greater efficiency)?

− what would the impact of those changes be on the overall cost model?

− would proposed revisions to the care model better or worsen safety within the care delivery model?

− how have other industries improved their use of human resources?

− who perceives that they are benefited by maintaining the status quo?

− who would resist transformation and why?


architecture is key to the discussion

• it can remove the walls that cause silos- design for cellular (multidisciplinary care team) care delivery- configure services/programs for achieving “measurable milestone

outcomes”

• it can facilitate more “bandwidth” of care in fewer sights (single bed service line adaptable environments)- creates opportunities for care providers to come together differently

(multidisciplinary care teams)- minimizes patient movement

• it can embed the “five big ideas of lean” into the design and project delivery to remove waste in the capital program1. collaborate, really collaborate2. increase the relatedness of the participants3. develop a network of commitments4. optimize the whole not the pieces


value streaming patient flowplanning for optimized care delivery

• operational benefits:- reduces steps and cycle times- eliminates handoffs- increases predictability of

workflow- enhances ‘lean’ commitments

processes- decreases staffing

requirements- improves quality of outcomes

• facility impacts:- less space required- fewer dedicated spaces- dissolution of departmental

fragmentation

from this... ... to this!unique questions often bring new answers that offer the opportunity to drive toward transformational models


• consolidates pre-admission/pre-testing and key patient administrative services into a single stop for adult and pediatric patients. − requires an integrated

multidisciplinary care team. services include:admitting, ECGs, lab, patient instructions, care pathways and discharge planning

− they may also include chest x-ray and even ultrasound

• outputs include: − patient admission to correct unit− patient diagnosis completed− patient cleared for procedure

improved efficiency through integration an example of cellular care concepts patient intake center


improved efficiency through integration an example of cellular care concepts integrated interventional services platform

• we build our network of commitments/our multidisciplinary care teams.

• restructuring through “transition planning”− involves deep collaboration − involves all layers of the

organization, reducing the number of departments (from 4 to 1)

− ultimately results in more capacity with less staff resources! (20-25% front line staff, 4 departments to 1= 60% or less management staff)

• outputs include:− procedure complete− patient successfully

discharged− patient successfully admitted

to correct unit

Conventional Model – Split Therapeutic Services

Unit of Service

Patients/Rm

Rms. Total Patients - Daily

Total Patients - Peak

Patients/Nurse

Nurses

Endoscopy 8 6 48 21 4 6

Surgery 2.78 18 50 25 4 7

Cath/EP 3 8 24 21 4 6

Spec Proc 3 2 6 4 4 1

Totals 190 71 20

Consolidated Therapeutic Services Model with Pre-Op/L2 Hub

(peak is at 11:00 am)

Endoscopy 8 6 48 21

Surgery 2.78 18 50 25

Cath/EP 3 8 24 13

Spec Proc 3 2 6 3

Totals 190 62 4 16

Front line staffing comparison


seeing the impacts of patient flow - conventional (current flows based on departmentalized critical access 24 bed facility)

OR

imaging

clinic

emergency

admitting

room type capacity

operating rooms 2

diagnostic modalities 4

exam/observ (incl. emergency/OR/clinic)

15

beds 24

total area (sf) 59,276

services metrics

admission 1step

lab/ECG/PFT/x-ray 12 steps

consult 2 steps

total steps 15 steps

total distance traveled

680 feet

total time 200 minutes

patient flow - the pre-admission testing patient(space drives workflow)


seeing the impacts of patient flow - optimized(optimized flow based on CareCyte facility configured for cellular team care)

OR

Clinic/ER/Dx

room type capacity

operating rooms 3

diagnostic modalities

(not including portable modalities)

2

exam/observ (incl. emergency/OR/clinic)

15

beds 30

total area (sf) 28,750

services metrics

admission 1step

lab/ECG/PFT/x-ray 3 steps

consult 2 steps

total steps 6 steps

total distance traveled

170 feet

total time 80 minutes

patient flow - the pre-admission testing patient(workflow drives space)

30 BED Acuity Adaptable Unit – single bed rms(shown)

Or

42 BED Inpatient Unit Incl. 6 single bed rms and 12 three bed rms


inpatient room as care cell

• inpatient rooms standardized/multi-zone allowing for maximum point of service flexibility- minor procedures at bedside

- space capable of flexing to ICU standard of care

- zones include:

¡ patient facilities zone (toilet, shower, wardrobe)

¡ significant other zone (rooming in, work counter or table - not to conflict with other zones)

¡ patient care zone, unencumbered nursing care minimum three sides of bed

¡ technology zone (data, infrastructure, gasses, power...)

¡ staff working zone (supplies, nurse server, charting at bedside)

• inpatient units to have localized point of care services and technologies- lab

- imaging - ultrasound, portable x-ray, ct scan

- respiratory care

- pharmacy (pyxis)

- pt, ot ...


the Sutter Prototype Hospital initiative

going from model to discussion to action

- the LAMDA cycle realized!


the approach: a “co-opetition”• in order to break from the conundrums of the current state, we

determined to share our models and objectives with multiple teams (set based approach to team formation) - entering into a discussion (build a common DNA) and making them actionable:− proposal split project delivery into a competitive planning and pre-

design stage followed by implementation by the ‘winning’ team (Sutter determined that based on predicted need based on successful attainment of objectives, sufficient project work would lead to ALL teams winning!)

− objectives/values set by owner:o patient safetyo staffing efficiencyo project adaptability/flexibilityo costs

− project teams were to self-assemble prior to proposing to participate(teams to include operations, programming, design and build participants)

− three teams selected to compete – each team awarded $500,000 to participate

− in kickoff meeting, teams were involved in determining metrics and actual delivery schedule


aspiring to greatness – prototype hospital objectives

• the teams agreed to strive to meet the following objectives based on Sutter provided facility baseline for similar care capacity:− improve workflow efficiencies by 40%

o reductions through reduced cycle times and elimination of unnecessary redundancy in patient flow

o revisions to care configuration based on cellular care concepts

− reduce facility area per adjusted patient discharge by 30%o reductions through elimination of unnecessary redundancy in patient flow and

excess queueso spatial configuration of services for cellular care delivery eliminates fragmentation

in care model

− reduce overall construction costs per bed by 50%o Develop design sets oriented toward high value to cost ratios

− reduce energy use per area by 25%


design sets – creating unique opportunities

• set based design concepts presented in the Sutter Prototype Hospital co-opetition− structural:

o long span inverted truss (100’x100’ grids)o long span truss coupled with standard span beams

(60’x30’ grids)o concrete versus steel

− mechanical:o decentralized HVAC and plumbing systemso vertical versus horizontal distribution systemso displacement ventilationo chilled beamo factory packaged systems and equipmento tightly ‘coupled’ systemso 100% outside airo prefabrication of labor intensive systems


• set based design concepts presented in the Sutter Prototype Hospital co-opetition−plumbing:

o solar water heatingo air admittance valves for vent systemso rain water/gray water retention and distributiono dual (high/low) flush valveso self-generating hydropower faucetso co-generation

−electrical: o solar generated electricity/nano-solar photo voltaic

systemso LED lightingo daylight harvesting

design sets – creating unique opportunities


highlights of lean project delivery

implementing the architecture we discovered in the co-opetition!


leaving no stone unturned: removing waste from the project delivery process

• target value design− sets criteria based on Sutter Health’s objectives for the project (value as

defined by the customer…)− couples building influence with early design thinking− designs to budget in lieu of estimating design

• lean project delivery− maximizes value to cost ratio (good is not enough)− emphasizes the five big ideas of lean− allows for set based design approach (in lieu of point based design)− initiates commissioning process when it can provide the most value

• these combined integrated project team strategies generate a substantial building systems knowledge base that can be applied to all Sutter projects


the five big ideas applied to lean project deliveryemergent outcomes

collaborate;really collaborate

projects as networks ofcommitment

tightly couplelearning w/ action

optimizethe whole

increaserelatedness

innovation competitive

continuousimprovement

reliability

buildtrust


innovation – the leadership team

SH Rep.

CM/GC PMArch. PM

FPDRep.

Senior Mgt.

Senior Mgt. Senior Mgt.

Senior Mgt.

Core Group/Senior Mgt.

IFOA


building trust – the integrated project delivery team

SH Rep.

CM/GC PMArch. PM

FPDRep.

Core Group

Civil

Structural

Mechanical

Electrical

Plumbing

Site

Steel

Mechanical

Electrical

Plumbing

Framing

Landscape

Landscape

OtherOther

Integrated Project Delivery Team


continuous improvement –promise performance

Conditions of Satisfaction

&Date of Completion

CUSTOMER

Request“Will You?”

Prepar

atio

n

1

3

4

PO

InquiryNegotiation

Clarification

&

Negotiation

Signed

PROVIDER

2

Performance

Declare Complete“I’m Done”

Accepted Submitted

COMMIT“I Promise I WILL”

Assurance

DeclareSatisfaction

“Thank you”


increasing reliability - Last Planner System

Last Planner System™


M/E/P

cluster leaders

structure

landscape

material handling

vertical transp.

site improvements

interior/ finishes

building envelope

optimizing competitive position: Target Value Design couples collaboration with optimization of the whole


creating the collaborative design environment

• CM/GC and trades have seat at design table• design-collaboration or design-build subcontractors

(MEP, Fire, Curtain wall, Skin)• sharing of intermediate design documents• construct-ability/build-ability inform design• value analysis throughout design• design-to-budget/over-the-shoulder pricing


optimize the project, not the pieces

• Contingency− Multiple contingencies – design, construction, escalation, and

project

− Late GMP – limits hidden “contingency” (Sutter bears the escalation and permitting risks)

− Jointly manage design and construction contingency

− Integrated Agreement – combines contingency making team performance paramount


optimize the project, not the pieces

• Limited “extras”− Limited change orders (scope, DSC, unforeseen regulatory or

code interpretation)

− Joint monthly meetings to assess reasons for “extra work” and financial responsibility


lessons learned

• Sutter Health has initiated 3 prototype hospital projects− key to success is clarity of scope (a key owner decision in which the

last responsible moment is at project initiation)

− optimized metrics are only possible if leadership is clearly aligned with strategies for meeting them

− transformational design requires participation of many disciplines at the inception of project thinking

− transparency is essential for project successo accountability must be balanced with the ability to make decisions

o do not underestimate the power of legacy mindsets/resistance to change

• The goals we established are achievable!


questions…

Documents

Leapfrog! - btmteam.net · Leapfrog! finding architecture ... annual ﬁnancial data ﬁle for report periods ended January 1, 2004 to December 31, 2004. ... lab/ECG/PFT/x-ray 3 steps