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Lean Facility Design as an Agent of Organizational Change for the Future of Health Care
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Lean Facility Design as an Agent of Organizational Change for the Future of Health Care



Presented on April 16, 2011 at the 2011 American Medical Group Management (AMGA) Annual Conference in Washington, DC...

Presented on April 16, 2011 at the 2011 American Medical Group Management (AMGA) Annual Conference in Washington, DC
Dr. Randall Huss, President, Mercy St. John's Clinic - Rolla Division
Gerald Dowdy, Vice President, Mercy St. John's Clinic - Rolla Division
Whitney Churchill, AIA, Architect, The Neenan Company
Dan Garofalo, Vice President Business Development, The Neenan Company
Using the acclaimed and highly innovative St. John's Clinic - Rolla facility as the kick-off for discussion, the presenters described how the Lean facility design served to drive Lean process improvement and a new model of patient-centered care. Presenters provided one-and-half-year follow-up data, including voice of the customer surveys, patient satisfaction, call center metrics, provider feedback, and lessons learned. An emerging national trend in healthcare organizations utilizing Lean facility design, as well as results that can be obtained, was discussed.



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  • Appropriate graphics to be selected by NEENAN after we receive information from Dr. Huss (any additional information needed???)Presented by DR. HUSS
  • Dr. Huss – confirm or add information – Neenan to assist with graphicsEfficient: design, flow, function and processesFocus: Patient-centered comfort and careTechnology: Fully digital, leverages robust EHRProcesses: PaperlessDesign: Support new model of team-based and patient-centered careClinic and hospital partnership

Lean Facility Design as an Agent of Organizational Change for the Future of Health Care Lean Facility Design as an Agent of Organizational Change for the Future of Health Care Presentation Transcript

  • ST. JOHN’S CLINICRolla, Missouri
  • Lean Facility Design as an Agent of Organizational Change for the Future of Health Care
    Randall Huss, MD
    President, St. John’s Clinic-Rolla Division
    Gerald Dowdy
    VP, St. John’s Clinic-Rolla Division
    Dan Garofalo and Whitney Churchill
    The Neenan Company
  • Region and Market Information
    Primary service area is four Missouri counties: Dent, Crawford, Phelps, Pulaski.
    Population: 2010: estimated 137,000 2015: projected 145,000
    40-45% market share with >180,000 patient visits per year.
    View slide
  • St. John’s Clinic
    550 physicians, 70 offices, 40 locations
    Integrated physician arm of St. John’s Health System
    St. John’s Health System ranked in Top 3 integrated delivery systems 2007-2011
    View slide
  • St. John’s Clinic
    Consistent Top 10 performer in Press-Ganeypatient satisfaction
    CMS Physician Group Practice Demonstration Project
    4 operating divisions
  • St. John’s Clinic is becoming Mercy Clinic
    1,300 integrated physicians
    350 mid-level providers
    4,000 co-workers
    4.4 million patient visits
    $670 million in net revenues
    360 offices in 4 states
  • Mercy Clinic Footprint
  • History and Background
    St. John’s Clinic-Rolla (2006-2007)
    Outdated buildings needed replacement
    Desire to consolidate 3 sitesinto 1 building
    EHR deployment upcoming
    Desire to add outpatientservices (HOPDs)
  • Leadership’s Decision and Mandate
    St. John’s Clinic-Rolla (2006-2007)
    Do not replicate MOB designof the past (even if others still building those)
    Build ambulatory healthcare facility of the future
    Efficiency: optimizeproject size (capitalconstraints), yet providefor maximumnumber of providersand services
  • Burning Platform for Organizational Change
  • Organization’s Vision
    Improve patient experience: patient-centered care, convenience and comfort
    Efficiency and flows: work smarter, not harder
    Physicians: offload tasks to others working at top of licensure
    Nursing staff: decrease steps and prep time
    Achieve team-based care model
    Integrate clinic and HOPD services:break down silos
  • Design-Build Team Vision
    Develop the facility of the future for ambulatory healthcare via partnering and collaboration
    Follow Lean principles
    Seek transformational design to support transformationalmodelof care
  • Health Reform Drivers
    Patient and staff safety
    Efficiencies: doing more with less
    Transparency and accountability
  • Mercy: A New Model of Care for the Future
    Improved chronic disease management
    Multiple access points/vehicles for care
    Transparency and accountability
    ACOs and Medical Home
    Demand for patient-centric care
    Catering to needs of our key patient types
  • Organization’s Drivers
    Operational efficiencies
    Improved access
    Integrated, coordinated care
    Team-based care
    Leverage technology and new EHR
    Build facilities that support new model of care
  • Innovation
    Seeing things differently
    Doing things differently
    Making a difference
    Converting problemsinto opportunities
  • Barriers to Innovation
    Traditional mindsets:
    “Too risky…”
    “Suppose it fails…”
    “Impossible, never been done before…”
    “Somebody has already tried it…”
    “Let me play devil’s advocate…”
    “My patients are different…”
  • Gandhian Engineering
    “Doing More with Less for more and more and more…”
    R.A. Mashelkar: Breakthrough designs for ultra-low-cost products
    less time
    less resources
    less space
    less capital
  • Nano - Tata
  • Opportunity and Challenge
  • The Ambulatory Health Care Facility…
    …of the future
  • Planning Challenges
    Bringing together practices and services from three buildings
    Integrating clinic, lab, imaging, pharmacy and new HOPD services (ASC, PT, sleep lab ) into “one stop shop”
    Transformation from traditional office receptionist phone model to call center model
    Design phase began prior to implementation of EHR
  • Planning Process
    Must first understand EHR workflows and capabilities
    Value Stream Mapping: Analyze patient visit process from beginning to end from patient’s perspective
    Apply Lean principles by eliminating waste, andnon-value added workand processes
  • Planning Process
    If process (e.g. registration) is non-value added but necessary, can it be redesigned or improved?
    Must understand/do Lean workflow redesign before facility and workspace design
    Leverage technology where possible: Don’t pave the cow paths
  • Leap of Faith
    Incremental or transformational change?
    National trends
    Cultural shift
  • Leap of Faith
    Incremental or transformational change?
    National trends
    Cultural shift
  • Road Trip!
    University of Utah Community Clinics “Learning Days”
    Lead architect, senior Rolla division leadership,middle management and physician skeptic on3 separate visits
    • Care Team Model
    • Lean workflow redesign for EHR
    • Call center serving10 sites
    • Redstone Clinic designed to Care Team Model
    • We liked it: we can do it!
    • Improve and notre-invent
    Road Trip!
  • Keys to Success
    Focus on patient experience
    Right person / right job
    Lean facility design
    Leverage andexploit technology
    Effective communication
  • Workflow Redesign: The Care Team Model
    • LPNs/MAs trained to advanced competencies
    • Participate in EHR documentation
    • Off-load physician tasks
    • LPNs/MAs notassigned to oneprovider
    Patient/Nurse image
  • Workflow Redesign: The Care Team Model
    • Up-staff LPNs/MAs per provider
    Provider and LPNs/MAs electronic workstationsco-located
    Move all functions notrelated to direct patient care out of suite
    Only caregivers in the suite
    Enhanced communication
  • The Patient-Centered, Physician-Efficient Visit
    Analysis of ambulatory office visit process from patient’s perspective
    Optimize physician time and satisfaction
  • The Patient-Centered, Physician-Efficient Visit
    Eliminate waste
    Eliminate steps:avoid provider leaving the room
    Minimize patient movement:bring care to patient
    Standard workflows, room layout and supplies
  • Lean Workflow Redesign
    Just-in-time (JIT) inventory, par levels
    5S: sort, separate,shine, standardize,sustain
    Standard room set-upand supplies
    Procedure kits: allsupplies organized,quick grab-and-go
    Printers in exam rooms
  • Leverage Technology
    Telemedicine rooms on each floor
    Videoconferencing/webinar technology in multiple capacities
    Training room
    Videoconferencemeetings 110 milesfrom main campus
  • Leverage Technology
    Call center metrics and monitoring technology
    My Mercy patient portal: Patient self-scheduling and messaging
  • Leverage Technology
    In-room checkout and next visit scheduling
    Communications care team (aka “call center”)
    Nurse protocols in call center for triage and refills
  • Lean Facility Design
    Analyze each element from Lean and customer perspective
    Eliminate process ifnon-value added or ifmain purpose is to support paper workflows
    Simplify wayfinding
  • Lean Facility Design
    Galleria: Patient-centered comfort; welcoming
    Eliminate paperstorage space
    Standardization: room construction, officesuite modules
    Optimize square footage
    Consider horizontal and vertical adjacencies
  • Lean Facility Design
  • Lean Facility Design
    Minimized greeting lobby over large “waiting room”
  • Lean Facility Design
    Private registration kiosk in galleria
  • Lean Facility Design
    2 levels with on-grade entrances/close parking
    Amenities:Mercy Mocha,Wi-Fi, drive-uppharmacywindow,patient-centeredcomfort
  • Lean Facility Design
    Shared provider lounges over individual offices
    Support Care Team model
    Care Team module: workspace redesign
    Call center
    Provide 3 roomsper provider on any given day
  • Lean Facility Design
    Avoid single purpose rooms
    Telemedicine rooms are also regular exam rooms
    Avoid “procedure room” designation
    Exam room configuration to support technology
    Flexible space: “swing rooms” between modules
    Extra points of carepicked up withelimination ofindividual offices
  • Lean Facility Design
    Reduced storage: anticipate JIT inventory
    Eliminate “break room”in each suite infavor of singleco-worker lounge(more amenities)
    Sterile/non-sterilecorridor entrancesto operating rooms
  • Transformational Changes
    Care Team model(Lean workflow redesign)
    Care Team module(Lean workspace redesign)
    Communications care team(aka call center)
    Partnership with HOPD operations
    Co-located in the same building
    EHR implementation – enabled transformation
    Lean facility design – forces change
    Minimizing waiting room, 70% less storage
  • Incremental Changes
    Just-in-time inventory
    Lean process improvement
    Immediate lab results(stat spin)
    Fully digital imaging
    Elimination of suite specific break rooms
  • So…how are we doing?
  • Patients
    Press Ganey Patient Satisfaction
    Significant drop first quarter
    Increases each of last 4 quarters
    All time Rolla achievement
    Voice of the customer
    76% rated experience as excellent / 21% as good
    Wayfinding and layout / design
    “One stop shop” healthcare
    6% noted privacy concerns
    Call center acceptance
    Appeal of the facility
  • SPACE – 13% Reduction
    CAPACITY – 16% Increase
    Entire Building
    Lean Facility Design Results
  • SPACE – 20% Reduction
    CAPACITY – 16% Increase
    Lean Facility Design Results
  • Facility
  • Business Performance
    +$2.8 M
    > 50%
  • Call Center
    Upgraded salary structure
    Increased nursing positions
    Lean Project
    4 month engagement
    Evolutions of Solutions newsletter
    Standardization of telephone process
    Developed in basket performance goals
  • Telephone Encounter: Scenario #1
  • Telephone Encounter: Scenario #2
  • Call Center Performance Metrics
    Call center software
    > 27,000 calls/month; 69% for issues other than scheduling appointment
    95% call answer rate
    < 1% voice mailbox message
    Agent/call display
  • Lessons Learned
    Call center conceptabsolutely right processimprovement strategy;did ultimately requireexecutive decision
    Communications care team and clinical care teams require continuous process improvement to maximize efficiency
    Care Team module design challenge forDragon dictation
  • Lessons Learned
    Challenge client toco-create change
    Look to change deliverymodel systematically,not incrementally
    Technology changes everything
    Lean facility design reinforcesworkflow improvements
  • Evolving Culture
    Accepting Care Team module
    Facility supports co-worker events
    Open architecture promotes interaction
    Clinic / Hospital fully integrated as a team
    Voice of the customer (co-workers)
    Overwhelmingly positive comments
    Suggestions of TV in pediatrics
    Common events
    Photo Contest
  • Visions/Goals
    In-room direct EHRscheduling at other offices
    In-room balance collections
    In-room lab draw,specimen collection
    Continue to reduce appointment rules and types
    Implement touch screen self check-in kiosk
    Continue to roll other clinics outside of Rolla into communication center
  • Visions/Goals
    Integrate/centralize Clinic,HOPD, pre-certification,billing andscheduling process
    Achieve NCQAPatient-Centered Medical Homefor primary care offices
    Billable e-visit
    Continue Lean process improvement
  • From Our Experience…
  • Do
    Continuously articulate a clear vision
    Design for the norm,manage to the exception
    Have an integrated team process between the design-build team, leadership team, providers and co-workers
  • Do
    Identify and enlist physician champions and participation
    Include the voice of the customer
    Design with the customer/patient in mind
    Follow patient-centric concepts
    Embrace Lean process improvement tools
    Share the knowledge
  • Do Not
    Be in a hurry and build the wrong facility
    Ignore the resistors – but do not allow them to hold design hostage
    Underestimatethe challenges ofthe call center andco-worker skillsneeded
  • Do Not
    Be afraid toembrace change
    Have sacred cows:instead, challengetraditional thinking in workflows, processesand design, andask why 5 times
  • Conclusions
    Implementation/optimization of robust EHR, combined with leveraging technology, provides opportunity for transformational change in model of care delivery
    Innovative facility design provides opportunity to facilitate transformational organizational change and support a new model of care
    Change is hard!
  • The Prince
    It must be remembered
    that there is nothing more difficult to plan,
    more doubtful of success,
    nor more dangerous to manage
    than the creation of a new system.
    For the initiator has the enmity
    of all who would profit by
    the preservation of the old institution
    and merely lukewarm defenders
    in those who would gain by the new one
    Machiavelli, 1513
  • Questions?