Carol Milgard Breast Center
Image from Clinic Design Website

The first quarter issue of the Patient-Centered Design Online Newsletter is up and features an article on Lean design for healthcare. I’ve often wondered what Lean Design is. It is a derivative of manufacturing experience, specifically that of the Toyota Production System (TPS). According to Tammy S. Thompson:

“Lean design is a system that focuses on understanding and meeting customers’ needs through engaging and investing in the development of employees. He explained that its goal is not to eliminate jobs, but rather to identify waste and inefficiencies in an assembly line process model and to empower every member of the team to contribute to successful outcomes, getting what they need, when they need it, in the correct amount, thereby eliminating waste.” ~ Lean Design is Patient Centric

As far as healthcare is concerned, the major issues the article presents are:

1. Over production: Scheduling all patients to arrive at one time
2. Waiting: Caregivers required to wait for the necessary tools to provide patient care
3. Conveyance: Transporting patients, equipment and supplies
4. Process: Numerous schedules in systems that are not in sync
5. Inventory: Wrong supplies in the wrong locations
6. Motion: Inefficient travel distances or unsafe movement for caregivers
7. Correction: Unnecessary time and expense to resolve a problem created by a flawed process, such as medical errors

University of New Mexico, Dental Clinic and Surgery Center
Image from Clinic Design website

The article directed me to the Lean Healthcare Research site, by Herman Miller. I found the article interesting. According to their research:

“This isn’t because healthcare workers are inept or uncaring. They, too, are often victims of systemic inefficiencies and of complex and ambiguous processes. While some estimates place waste in healthcare between 30 and 40 percent, “the reality of what we’ve observed doing minute-by-minute observation over the last three years is closer to 60 percent,” says Cindy Jimmerson, founder of Lean Healthcare West. *4 In fact, when one director of process improvement tracked nurses on a typical shift, he found they typically travel over five miles, much of it in wasted motion. *5” ~ Lean Healthcare: Applying Herman Miller’s Expertise to Improve Outcomes

Most of Herman Miller’s points deal with implementation problems, namely, how staff members can be more accountable and take ownership for tasks. The curious part is where design happens in Lean Solutions. Obviously, Herman Miller is using it to sell their own modular casework, a strategy many companies use. However, one major point is obvious:

In her report on the design of this laboratory, the manager wrote: “When designing the layout of a lean laboratory, flexibility is of key importance.…Adaptability and expandability within the laboratory can be greatly improved by the investment of flexible casework. Flexible casework provides a convenient method for easily modifying and configuring work cells.” ~ Lean Healthcare: Applying Herman Miller’s Expertise to Improve Outcomes

I find the characteristics of Lean Design similar to Evidence Based Design (EBD). As Lean Healthcare indicates:

The basic approach of TPS is to first understand the needs of the customer, then “go and see” every step of a process, whether it’s admitting a patient to the ER or installing a dashboard in a car, to determine whether it adds value in the customer’s eyes or is waste. Ambiguity is removed from processes by clarifying who is responsible for each task and exactly how and when that task will be performed. As problems are uncovered or better ways to complete the task are identified, they are addressed immediately with quick experiments to test the change. In that way, flexibility is built into fixed processes, and “root problems” are uncovered and corrected before they become embedded in the system. ~ Lean Healthcare: Applying Herman Miller’s Expertise to Improve Outcomes

This is similar from the way I learned to practice architecture. My boss once told me that because their designs weren’t working, they sent a student to find out and document everything a nurse did during her/his shift. This is EBD before it was even named, and its good design practice.

Evidence-based design (EBD) is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. ~ EDAC The Center for Evidence Based Design

Both practices evaluate what happens in the workplace before any design takes place. They look at the possibilities for improvement, and continue to monitor the differences long after construction is complete. The only differences I can see between them is 1) a company intent on selling their product promotes Lean Design and 2) Lean Design also tries to improve employment. I see both as a model for building and processes commissioning. And maybe I’m wrong, but perhaps a manufacturing plant is the wrong way to view a hospital. Maybe it would be better to look at buildings with various flows of items, people, and systems, like airports.

To any readers out there, which system do you prefer, Lean or EBD, and why?

*****

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1. The Shape of Healthcare, by Derrick Teal

The Upper Cumberland Regional Health Facility (UCRHF) is:

Owned by the State of Tennessee, the new construction of this 50,000-square-foot facility building was essential for compensating for the recent and expected growth of the regional health department. When construction finally came to an end in 2010 and the doors were opened, this headquarters for public health services would act as the command post for any public health emergencies that would arise in the region while housing supervisory and support staff for all of the surrounding counties’ public health facilities. ~ The Shape of Healthcare

The Upper Cumberland Regional Health Facility oversees the health departments in a 14-county region and provides regional medical specialty clinics, such as tuberculosis, women’s health, HIV and genetics. ~ Greensource: The Upper Cumberland Regional Health Facility

The roof line, siting, mechanical and energy sources are all well-thought out, contributing to Tennessee’s first LEED platinum building. At only 50,000 SF its a smaller hospital, falling under the category of the Small Hospital, Big Idea competition. The health facility is mostly administrative under the large sculpted roof designed to minimize extra heat from the south while increasing daylight for the interior. I would love to see LEED Platinum achieved by more clinical and emergency services.

2. Design is Preventative Medicine, by Brooks Rainwater

This article focuses on the other design issues that pertain to healthy buildings. As the author points out, most people think building green is primarily about sustainability, (like reducing water and electrical consumption), and as important as it is for well-being,

The architects’ role is not only to design exceptional healthcare facilities, but to also design communities that promote wellness. We as a nation have been spending billions of dollars on drugs and other medical innovations to cure those that have become ill. With healthcare costs in the U.S. projected to grow toward nearly 20 percent of GDP by 2020, can we really afford to continue down this current path?…

Place is reflective of health. Studies have shown that people living in urban areas are in better shape than individuals living in suburban and exurban communities. When you think of why this is, it is actually rather intuitive — city dwellers often walk, bike or take transit to work; they walk to nearby services like grocery stores and dry cleaners, and for other day-to-day necessities; and they live in smaller homes and therefore take more advantage of community amenities like parks and trails. ~ Design is Preventative Medicine

Brooks Rainwater writes an excellent article that points to items most sustainable and social architects want to think about. She cites the new Cooper Union Building by Morphosis as an example, which uses a skip-stop elevator to promote walking (for those who don’t require accessibility). In some ways, she’s ‘preaching to the choir’ of supporters by writing this in a magazine focused on environmental design. I would love to see more examples of ‘Preventative Design’ and the studies she references in magazines for developers and other businesses. The place to influence design and prevention responsibility lies not only with the architect, but in educating the clients as well.

Over all, I would recommend to anyone interested in sustainable/environmental design sign up for the EDC magazine because it has a lot of relevant articles for the profession, from details to broader topics. The digital edition is free, but there is also a print edition available for a fee.

*****

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image from The Mental Health Commission of Canada

Monday, the Mental Health Commission of Canada announced the first mental health strategy for Canada.

Formed in 2007 by Canada’s Conservative government, the Commission has a number of studies, including creating a comprehensive plan for preventative mental health care across Canada. I can’t find the actual report, though I am looking forward to reading it when I find it. In the mean time, check out the webcast here. Unfortunately you need to register first.

I have a couple of thoughts even before I dive into the topic.

I know the Conservative Government is changing the funding structure for general health care across the provinces. The Star points out that it links it to 7-9% of health care spending, which equates to $4 billion devoted to mental health care. I welcome the proposed spending, however it sounds like such as large number, especially when governments are trying to pay down their deficits. Even though it’s a study required by the federal government, they don’t need to heed the spending recommendation. When doctor fees are cut to save $338.3 million in Ontario alone, I don’t believe the Canadian and Provincial governments will spend the billions of dollars on mental health care, even if it saves them money in the long run.

Second, the Commission put the report out to newscasters and journalists, but they are making it difficult for the public to read the report. The report should be completely public, especially when mental illness affects 1 in 5 Canadians.

What do you think about the Commission’s strategy?

*****

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CSA-Z8000-11 1-Hour Webinar

A few weeks ago, I watched the two-hour Complimentary Web Information Session on the New Standard for Design and Construction of Canadian Hospitals & Health Care Facilities (CSA Z8000-11). It was a 2  hour presentation and question period introducing the standard from a panel of authors. This webinar no longer exists, but instead, you can purchase a 1-hour one on how to use the guide itself.

The Z8000 Standard provides requirements and guidance for the planning, design, and construction of Canadian health care facilities. It is intended to be used by all facilities providing health care services regardless of type, size, location, or range of services. The Health Care Facility shall be planned and designed through the use of a project process, which includes several stages of planning to identify health needs of the catchment community and the expected role of the Health Care Facility; the translation of those needs into services/activity levels; and calculate space requirements of the services and a facility plan to accommodate the space. Each step in the process builds on the previous and a complete planning process should maintain this sequence to ensure a fully integrated and thought-out facility plan. ~ the description for the CSAZ8000 webinar

The CSA Z8000 is a complex 400+ page book, outlining all the different programmatic elements that can take place within a health care facility. Meant more as a guide than a manual for healthcare design, the group that put authored the CSA Z8000 (made up of architects, healthcare professionals, provincial ministry experts) hopes each province will adopt the standard as part of their building codes, thereby enacting the minimum requirements into law. For now, the provincial members plan to use the standard as part of the RFP (request for proposal) process, streamlining the application process for consultants and P3 (Public-Private Partnership) projects. When design-build groups propose buildings, the Ministry of Health can use the guide to evaluate the types of spaces being used, the requirements for adjacencies, the required elements within the spaces and their sizing to determine if the buildings supplied are comparable across the country.

I’ve worked on both Healthcare Facilities (Orillia Soldiers’ Memorial Hospital – OSMH with Parkin Architects Limited in Toronto among others) and I’ve worked on initial designs through complex programs (OSMH and the Earth Systems Science Building feasibility study with Colborne Architectural Group Pacific, Ltd.). While the new healthcare standard doesn’t replace proper programming for hospitals, I think it will help anyone doing initial schematic design and master planning proposals as they try to get initial planning concepts down. Tables that guide adjacencies, combined with alternate arrangements, reduces the constant “reinventing of the wheel” that often takes place during the initial design phases. However, on the other side, it may eliminate some questions that should be asked on occasion, like “should these 2 units really be put next to each other? what if we separated them?” These questions propel designers to rethink hospitals, and inspire projects like the winners from the Small Hospital, Big Idea Competition.

If you’d like to participate in the live webinars, they occur on May 22nd and May 29th, 2012.

In the mean time, has anyone started using the CSA Z800-11 as part of their design? If so, please let me know what your experience has been.

*****

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1. I established a better baseline for working with existing specifications in our office. The course taught me what to look for when coordinating existing specifications from suppliers within our office’s specification framework. Although now, I really want to go through our office specifications and rework them entirely, especially to format them to PageFormat Standards.
2. The course taught me to write specifications more effectively. If a contractor has to read a project manual, he wants concise, clear, accurate and consistent information at his fingertips. Again, in my office I want to go through our existing specifications (especially those for our corporate clients) and rework them so the language is direct and doesn’t contain lines like “the contractor shall.”
3. The online course gave me insight into other groups of specification writers. The online discussion groups through the mySAIT.ca website gave me glimpses into the lives of future Certified Construction Contract Administrators (CCCA) and Certified Technical Representatives (CTR) and what their priorities are when they sell products or manage construction sites. Even though future courses would be in a different stream, I enjoyed their perspectives on the course, with their views on the appropriateness of luncheons and marketing, compared to our professional mandate of showing complete impartiality.
4. The course covered a wide variety of topics related to specifications. I found the legal aspects the most interesting. I’m still not completely sure how Tort Law and Arbitration work in real life, but I believe I’m going to have to look up construction law blogs to follow-up on the topic. In particular, I’ve looked at articles from US sites about litigation over Green Building claims. I’d like to know how the cases turn out.
5. I’ve seen the repercussions of poor specification writing on site. I’ve been doing third-party reviews for a P3 (Public-Private Partnership) project daily for the last 3 weeks, and I can see how the scope of the specification statements (the PSOS statement) impact the project’s completion. I don’t know how shop drawings were approved with the wrong materials, nor how specific situations were accepted because I wasn’t involved from the beginning of the project. Where were the mock ups (01300 – Submittals)? Where were the referenced standards (Plywood vs Particle board in AWMAC)?
6. The more I look into specification writing, the more I’d like to know. I don’t necessarily want to be a specification expert, and I’m not sure if I’ll apply for furture courses or try to get a Certified Specification Practitioner (CSP) or a Register Specification Writer (RSW), but I have more questions now than I got answers for in the course. Does a project manual and the conditions in Division 1 have the same contractual obligation for a Construction Management (CM) contract as it does for a Stipulated Sum contract, when the Project Manual doesn’t contain the CM’s contract information? How do we tie those documents together more effectively? How are PSOS documents used in specifications for P3 projects?
7. I found the online forum good, but strange. While it worked with my schedule, I found the “at your own pace” learning style a bit difficult. I haven’t done term-styled learning since 2008 when I took a building code course at BCIT, but that wasn’t online. Since then I’ve studied for all my NCARB ARE exams in 5-6 week chunks, every night, then proceeded to write the exam. I found the information difficult to remember on a week to week basis. A physical classroom might have scheduled my time and impressed the deadlines in my schedule a bit more.

Altogether, I really enjoyed the class, and learned a lot. I’m debating taking the Specifier 1 & 2 courses, since they get more in-depth into specification writing. But, I think I’ll wait until I’m officially licensed with the OAA, and use the course to build up my Continuing Education hours.

Does anyone else have any questions about what I learned from the course? Stay tuned, and I’ll let you know how I did in the end.

*****

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Banner for USGBC LEED 2012 Development
Image linked to USGBC Website

If you are a member of the USGBC you can vote and comment on LEED 2012 revisions until March 20th. This is the fourth round of commenting, and the balloting period begins in June.

If you are like me, not from the US, you can still review and comment on the drafts, and you can even use the #LEED2012 Twitter Hashtag to have your say there. Make sure you look through the ‘Important Resources’ Section, including responses and comments from the second round of comments.

Follow the LEED 2012 blog here.

Has anybody seen anything there they want to comment on?

*****

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MNLB Kaiser Permanente Small Hospital Big Idea Competition
Courtesy of Kaiser Permanente

The winners for the Small Hospital, Big Idea Competition are Aditazz and Mazzetti Nash Lipsey Burch/ Perkins+Will (M+NLB). According to the Kaiser Permanente (KP) website, the winners were chosen for designs that:

• Create spaces to inspire human-to-human connection and collaboration
• Include civic spaces that blur the boundaries between the community and the traditional hospital setting
• Bring nature inside with light-wells and rooms that are oriented around a large central courtyard, building on research that shows a positive correlation between exposure to nature and healing
• Move beyond carbon neutrality to restore ecosystems and biodiversity, and improve the conditions for community health
• Make use of a unique tool that applies silicon-chip technology to the building and design process, enabling designers and frontline professionals to quickly explore an almost unlimited number of operational and space scenarios

GSP Kaiser Permanente Small Hospital Big Idea
Courtesy of Kaiser Permanente

It’s interesting that Gresham, Smith and Partners (GSP) was the only one of the 3 Finalists who didn’t ‘win’ the competition. GSP’s slideshow on the KP website was the only presentation with hospital room designs provided. They provided hospital room designs and images of daylighting savings and patient room air circulation. M+NLB’s presents images of patients wheeled throughout the entire hospital on electronic sensing beds. I have no problem bringing patients into nurturing natural and social environments, in most cases patients benefit from the variety of situations. I question these hospitals handle patient rooms and security, when they are able to move around. How do you prevent infections from spreading in those social environments. I’m relying solely on their description of the room. How staff members know if something is wrong when they rely on the technological bed to tell them if a patient is doing okay. What happens when they have to use the washroom?

Aditazz Kaiser Permanente Small Hospital Big Idea
Courtesy of Kaiser Permanente

The winners, on the other hand, clearly show that patient visitors and staff are a larger priority, by providing sustainable and interactive spaces that attempt to look like a community centre rather than a traditional hospital. Perhaps the ideal patient rooms of these entries are part of earlier rounds. I found the outdoor spaces in all three entries were the most engaging images. Given the hot climate of these hospitals in the competition, I question how useful these outdoor spaces actually are, though I realize they are using sustainable principles to create natural temperature differences.

All in all, I found the Small Hospital Big Idea competition fascinating. I wonder how successful these projects will be in the US, since we have a primarily public funding formula here. While it helps me imagine what a hospital could be, I think staff members, communities and provincial governments object to spending the money on such spaces when they could fund equipment, operating rooms, NICU units, or additional staff members, especially in our colder climate. Designers need strong environmental energy-saving arguments to compete with tight funding formulas with little wiggle room for additional up-front costs.

What are your thoughts on the competition? Do you agree with the winners? What do you find most inspiring?

*****

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As I researched material for our firm’s mental health prospectus, I discovered the American College of Healthcare Architects (ACHA) certification for Healthcare Architect. I was really interested in applying, until I discovered that I need at least 5 years of licensed architectural experience in healthcare architecture. In order to apply, I have to present a portfolio (3-9 projects) of my healthcare experience, including 3 reference letters from architects outside my firm, 3 letters of reference from clients, a passport photo, and a fee, all just to let me apply to take the exam for certification.

I want to update my healthcare architecture experience; this is difficult to do because I don’t work for a firm with significant healthcare experience. I developed some expertise working on hospitals during my work terms at school, and then in mental healthcare architecture while writing my thesis in 2005-2007, Supportive Housing for Mental Health Recovery: A Bio-Psycho-Social Perspective.

Since completing my thesis my experience in healthcare architecture has been limited to the Gathering Place (a community centre for the homeless and at-risk population in Vancouver), and as a 3rd party Deficiency Reviewer to CAMH’s Phase 1B building B2. But this isn’t enough for me, and though we try, my firm hasn’t yet secured any healthcare work.

This means that I can’t begin to apply for my ACHA designation for at least the next 5 years. It also means that I’m really looking at whether or not I really want to pursue Healthcare Architecture. For the first time in my life, I’m not just going for a designation because I should, but I’m actively deciding if its something worth pursuing. This has given me a few questions:

• How important are specialty designations? In an architectural practice where we’re supposed to be masters of many types of buildings, is it wise to pursue such a specialty?
• Is the ACHA designation worth anything in Canada? Are there any Canadian architects with the ACHA designation? Has it impressed clients? Or, has it just been an additional certification you’re simply managing within the profession?
• How much time should I spend on CE? Once I become licensed, I have CE requirements that I need to fulfill to maintain my architectural license. I need 70 hours every 2 years (35 per year) that I get through conferences, luncheon presentations, courses, etc for the OAA. In addition to that, I need to achieve 30 hours of CE experience to maintain my LEED AP BD+C designation every 2 years. Construction Specifications Canada requires CSPs to maintain 15 CE hours per year. The ACHA requires 18 Learning Units (US versions of CE hours); 12 units must be healthcare related each year. I either have to make every CE hour I do perform double (or triple) duty which requires time and effort for tracking, or I will be spending at least 83 hours per year maintaining those designations. That doesn’t even count if I want a license in a second province, like BC, where the AIBC requires 30 hours per year CE as well.
• Is this something I should pursue and does this affect my other goals? If healthcare architecture is my passion, then I need to look at my life and the time I spend on other items and decide how much effort I should devote to it. Should I let other goals affect my time maintaining my hours like fiction writing, knitting and running?

If anybody has any tips for managing time for CE hours, I’d love to hear them. Actually, I’d love to hear any tips you have on managing your goals and your time? How do you balance your goals, family and work life?

*****

Connect with me on Twitter, Facebook, and LinkedIn. Plus, sign up for free e-mail updates from this blog in the top right-hand corner of the page.

If you are like me, not from the US, you can still review and comment on the drafts, and you can even use the #LEED2012 Twitter Hashtag to have your say there. There will be a live chat event Thursday March 8th, 2012, at Noon EST on Twitter with USGBC president & CEO @RickFedrizzi

Follow the LEED2012 blog here.

Has anybody seen anything there they want to comment on?