Three hospital case studies demonstrate how eliminating waste leads to continuous improvements and cost savings. One hospital reduced overall costs by $7 million, applying the savings to a variety of facility enhancements.
A construction and design team’s primary focus is delivering value to the client. Anything that makes a project run more efficiently and with better outcomes is desirable. Naturally, packing that value into a box that is also less expensive to build and operate is a critical part of the equation.
In recent years, Lean processes have become a key fixture in the construction industry, offering teams the opportunity to leverage maximum value from a project team and shift that value into a new facility.
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What is Lean, and How Does it Work?
Lean construction encourages creative, collaborative thinking and promotes continuous efforts to eliminate waste of time and resources while delivering the best value. Combining operational research and practical development in design and construction, Lean processes focus on the holistic pursuit of concurrent and continuous improvements in the built and natural environment emphasizing these areas:
By minimizing waste across the board—everything from materials and inventory to time and transport—Lean drives efficiency, not only in construction and design, but also in the functionality of a facility. For healthcare facilities, this is essential, as it can help support clinical outcomes and transform the industry.
Three recent projects, each in a different geographic location, stand out to me as strong examples of how implementing a collaborative approach and some fundamental Lean principles helped lay the groundwork for success.
Virginia Healthcare Facility Using Design-Build
In Marion, Virginia, the Smyth County Community Hospital, which is part of the Mountain States Health Alliance hospital system based in Tennessee, was planned as a new, 156,759-square-foot hospital and professional office building to replace the existing hospital. The the new facility wouuld offer wide range of state-of-the-art amenities, including the following:
- A 13-bay emergency department
- Three operating rooms
- Four intensive care unit rooms
- 14 rehabilitation beds
- 18 medical-surgical rooms
- Dining services with a dining hall
- An imaging department with an magnetic resonance imaging suite
- An oncology suite
- Administrative and support space
Circumstances made this project a natural fit for Lean practices. The client contracted the design and construction together under a design-build contract in order to more strongly align all three parties and create better project outcomes. From the start, the team was charged with designing and building a highly efficient facility that met the needs of the program. From the onset, improvement over existing conditions was the goal and the team had the ability to question preconceived ideas, challenge each other, and make improvements as the project progressed. Unlike traditional design-bid-build in which design documents are delivered before external bids for construction are solicited, design-build is characterized by in-depth collaboration between the design and construction teams from the beginning.
Collaborative arrangements such as design-build are efficient because they integrate all project resources and allow the design and construction teams to work together. For example, early in the design process, the entire project team evaluated the programming of the hospital, including the number and size of patient rooms and clinical spaces and reduced the building size by 15 percent based on what would best serve hospital patients, leadership and staff. This process was followed in all major clinical and operational spaces including surgery and diagnostics and treatment. The end product was a smaller, but right-sized, facility with lower capital expenditures and operational costs.
To further enhance collaboration, the team utilized building information modeling (BIM), which offers a digital representation of the functional and physical characteristics of a facility. The construction and design team used BIM to consider key decisions for the facility during its life cycle, from the earliest conceptual stages to the end of life (i.e., demolition).
Short-term benefits to this multifaceted approach included the following:
- Better coordination of documents, which increased quality and constructability
- Better overall understanding of the project and process, as all parties were actively involved from the start
- Fewer requests for information (RFIs) and change orders
- Reduced project schedule by 4 months
- A stronger sense of collaboration, which led to more effective team communication
In addition, there were a number of long-term benefits from utilizing a design-build approach that highlighted quality, constructability, and ease of maintenance among others. These results were realized from the increased coordination of documents and project plans. Such benefits included:
- Limited warranty work, which was a direct outcome of the higher-quality product that was put in place resulting in fewer calls for warranty issues.
- Increased quality, ultimately leading to better building maintenance.
- Greater preparation for future building additions and renovations that was accomplished during the design phase by preplanning where future expansion would occur―a move that will reduce disruption and costs when departments are expanded and provides a roadmap for future growth.
Sutter Health Implements Target Value Design, the Big Room, and A3
Another example of Lean construction success is Sutter Health’s 18-acre site development in Palo Alto, California. This project included a new outpatient center with the following elements:
- A clinic
- A common area
- An ambulatory surgery center
- A parking garage (1,126-car capacity)
Sutter Health was an early adopter of Lean methods such as integrated project delivery (IPD), an approach that brings together the client, designer, and builder in order to align stakeholders and streamline the project’s execution. Because there were so many stakeholders involved, it was critical to establish effective communication systems from the outset, and for the project’s duration. As a result, all parties—the owner, designer, and construction leader—signed a tri-party integrated form of agreement, which helped set the foundation for a larger collaborative process based on shared risk and reward.
The next step in this project’s process was to participate in a Lean target value design process, which sought to ensure that the owner got the most value for its budget by validating the estimated cost during the design period, rather than after the design was complete. This process reduced the overall cost by $7 million allowing the team to apply these savings to a variety of facility enhancements such as higher-quality finishes, additional medical equipment and the build-out of the third floor which was originally shelled space.
This tri-venture also used the Lean principle of the “big room,” which is the co-locating of an entire project team in one physical space to encourage collaboration. The team designed and built an 8,000-square-foot workspace with no partitions, which helped foster easy, informal, and frequent interactions. One element important to Lean is “reliable promises”―co-location and intermingling with different disciplines heightened this. Individual actions, or at times inactions, were visible and the impact was immediate (i.e., making or missing deadlines). This transparency held team members accountable for their actions and those of the collective group.
Using the Lean practice known as “A3,” a problem-solving approach based on three steps—examining the problem, identifying possible solutions, and evaluating advantages and constraints of each solution—the team in the big room assessed the lowest total cost for critical and redundant systems across the medical center.
For example, the team had to find a solution to allow for optimal function of hands-free sensors for 350 faucets. Sutter Health sought an option that was low maintenance, unlike traditional battery systems that require routine care, and assessed several options from both time and cost perspectives. The Sutter Health and design team worked collaboratively to choose faucets that use eco-powered batteries that, though more expensive initially, offered cost and time savings in the long run.
IPD Overcomes Initial Challenges in New Jersey
IPD also has been an essential component for a New Jersey healthcare facility in its early construction stages.
This 446,000-square-foot facility was the healthcare facility’s first project using IPD. The IPD team was bolstered by our design assist trade partners―mechanical, electrical and plumbing subcontractors―who brought extensive knowledge and hands-on experience to the project. These partners helped identify coordination efficiencies, such as decreasing utility depths beneath the facility by two to three feet, which saved roughly $49,000.
Another example of Lean collaboration driving efficiency on this project came with the initial design of the facility. Specifications for the project required that the hospital provide emergency power for the various building and life safety systems, per building codes. To enhance redundancy and expand the scope of services that the hospital could provide during power outages, hospital leaders wanted to add additional building systems to the emergency power system. Adding these systems to the emergency generators would increase the size and number of generators required, at an additional cost of $1.1 million.
This prompted the IPD team to reassess initial designs. We found an alternative solution that took advantage of other planned systems and equipment, resulting in a net savings of roughly $277,000.
Understanding the hospital’s operational needs allowed the team to offer a more complete response to the opportunity via a better design and construction solution.
Using Lean to Drive Efficiency in Building Design and Construction
With each of these projects, having a Lean mindset resulted in positive results.
While hospitals have grown in size and complexity over the years, their physical layout has not kept pace with technological innovations, nor truly taken advantage of evidence-based design. They may look and feel different, but that doesn’t make them operate better.
Lean tools and practices grant construction and design teams the opportunity to change the way facilities are built, which ultimately impacts the way doctors and nurses perform their work.
It’s not enough to simply ask ourselves: “Can these hospitals be built better?” Lean design and construction can help revolutionize how hospitals are designed and built, and how they operate when we’re gone. It can help keep the focus on utilizing the right materials and processes, which can help create a facility that stands the test of time.
Andrew Quirk is senior vice president at Skanska and national director of its centers of excellence.