Bromley Acute General Hospital
How can design support the modernisation of services to improve flows and enhance the patient experience? What impact do care networks and patient pathways have on the location and shape of the built environment? How can design support more productive processes? How can design keep pace with clinical change?
Traditionally organisations are seen as a collection of departments or activities, managed separately, with time buffers between them. 'Lean Thinking' sees an organisation as a collection of customer, provider and support processes, and aims to deliver quality and value, eliminating waste.
Lean Phase One
There are three phases of 'lean development' and the health sector is currently operating in the first of these: Modernisation Agency pilots and the Osprey programme show better outcomes and less wasted time and cost.
Lean Phase Two
Learning to redesign whole pathways: these will aim to reduce waiting times, and show us how to change buildings to fit in several parallel flows with dedicated facilities. This will minimise time and distance through the hospital.
Lean Phase Three
Applying this approach to the whole healthcare system. This will probably lead to several alternatives to the current 'Big Box General Hospital' with large office areas, big waiting rooms and car parks for storing patients: big centralised machines with low unit costs but lots of waiting, and big storage areas buying cheap and storing high.
Patient flows
This approach needs a paradigm shift in organising services: from batch to flow logic. It rationalises patient flows and requires standard service delivery templates based on the similarities of patient needs. It minimises movement and storage. It also changes how services are delivered, using technology to support rather than limit patient flows. Standardisation is often considered to kill creativity, but experience shows it does the opposite.
Recent projects in ambulance, sterile services and A & E using process mapping techniques show the importance of involving users in pathway redesign. A pilot at Portsmouth Hospital is introducing hand held technology to assist nursing observations. This can support system redesign by providing better information on interpreting observations. It shows how to design services to stream patients to receive care based on their needs, rather than the convenience of the hospital. This gives nurses more time with patients who require more care.
Observations from other sectors
Examples from airport and retail sectors suggest that we are moving away from 'big boxes' that align with mass production towards a solution focused on customer convenience: more distributed, located close to other facilities, with minimal waiting times. The experience of the customer is key to 'Lean Thinking' and in a competitive market they will probably 'choose' where to access care based on outcomes and personal experience. An emphasis on customer circumstances rather than attributes is central to 'Lean'.
Implications for the physical environment
Examples from the commercial office and education sectors show how thinking has shifted from bland open plan offices based on mass production to workplaces based on tasks and activities. Working outside the office using mobile communications is commonplace. In education the emphasis on self directed, project based learning is changing the kind of spaces. Whilst we have detailed understanding of the formal places for learning such as classrooms, we still need to explore the potential of the 'spaces in between' to support informal interaction and knowledge exchange.
Several 'Lean Thinking' projects in US health facilities use flexible design to allow future change by:
- concentrating on robust vertical and horizontal circulation routes
- recognising the importance of integrated work flows between diagnostics and treatment eg in theatres
- standardising designs for surgical unit and patient bedrooms to accommodate changes in work loads over time
- regarding waiting as an educational opportunity
- using technology to provide information to patients and staff to support speedy journey through treatment
- testing different uses for space that are likely to occur over time.
The overall layout of the building needs to promote patient safety, create the best working environment and recognise the unique needs of patients.
Whatnext?
Changing cultures takes a long time and requires close collaboration and understanding.
Strategic thinking needs to be captured at an early stage in the project. This needs to be supported by a good guidance process. Demonstration and pilot projects would help to take this forward.
Key messages
- 'Lean thinking' needs to engage decision makers: clinical staff, managers, health planners, designers
- The need to move from isolated good practice to whole systems pathways and system reform is required
- Sharing information about good practice is urgently needed
- The potential for technology to assist needs to be further developed
- The implications of system redesign for the design of the physical environment needs to be better understood
- Both clinical and design staff could benefit from training
- The Design Brief is key to communicating information about service redesign
More information
The Lean Enterprise Academy
As FHN is now closed, these pages will no longer be updated.
