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Industrial engineering principles enhance hospital design

By Harriett Linenberger, PhD, RN, Hammes Company Senior Operational Planner

The manufacturing industry is known for its revolutionary industrial engineering techniques and cutting-edge efficiency. These methods now are being used in hospital design and construction, resulting in improved operational efficiency, staff utilization and patient safety, while reducing overall costs.

Typically called process engineering or management engineering within healthcare, industrial engineering has it roots in the automobile industry beginning more than a hundred years ago with Ford Motor Company. It has evolved into specialized methodologies and tools refined in recent decades by companies such as Toyota, Motorola and General Electric. Lessons learned from these giants prove that the reduction of variation in products and services has a great impact on efficiency and therefore, profitability.

“You get a better building when you use process engineering methods. They improve the efficiency of healthcare services and increase patient satisfaction,” says Rich Galling, President of the national healthcare development and management firm Hammes Company.

Implementing process engineering
According to Mr. Galling, the benefits are realized when the building is complete. Facilities that have incorporated management engineering in their pre-design and design stages enjoy substantially lower operational costs across the board, particularly in personnel, equipment and supply utilization.

Process engineering techniques are becoming increasingly popular in the conceptualization, pre-design and design of new hospitals across the country. Some hospital facilities use multiple methods and employ management engineers on staff to support implementation, while others are using a hybrid approach.

“Engineering methodologies… such as Lean and Six Sigma… have radically improved manufacturing in the last few decades; there is no comparison to what manufacturing was like before they were developed. As our economy spends more money on healthcare, both in absolute terms and relative terms, it is becoming extremely important to streamline our health systems and delivery utilizing these methods,” says Hari Srihari, PhD., Chairman of Systems Science and Industrial Engineering, State University of New York at Binghamton.

“There may be a higher cost associated with building a hospital complex initially using these methods, but over time the operational cost savings more than make up for any additional construction debt,” says Mr. Galling. “For example, engineering techniques optimize facility functionality and improve efficiency so the facility runs with the most efficient number of FTEs,” he noted. “In other words, a strategically designed facility can operate at maximum efficiency with less staff.”

Three hospital groups use process engineering in different ways
Hammes Company has worked with healthcare clients including New Jersey-based Virtua Health, Elmhurst Memorial Healthcare near Chicago, and SSM Healthcare in St. Louis that have successfully incorporated management engineering and process improvements in the pre-design and design phases of their new facilities.

Virtua Health combined Lean and Six Sigma with management engineering techniques to develop six new building designs
Virtua Health followed a formalized approach utilizing many methods and techniques, including Lean and Six Sigma. Its in-house staff of management engineers is headed by Tejas Gandhi, Director of Management Engineering. “Historically, operational processes were tailored to the facility’s design, but this approach hinders healthcare in terms of future staffing and throughput,” said Mr. Gandhi. “Technically a building may look great, but in terms of workflow and operational efficiency it may not be the most appropriate design,” he added.

Virtua took ten months to study its existing facilities, do some “out-of-the-box” thinking and come up with the best possible operational design for the future hospital complex before designing its new greenfield campus in Voorhees, New Jersey. Lean was used to find and eliminate waste. In a hospital, time spent moving patients is one of the biggest sources of waste, tapping valuable staff time. Working with special time-saving techniques, Lean helps to systematize waste elimination.

Current-state mapping was one procedure to determine workflow in Virtua’s present hospital complex. Management engineers followed staff, such as RN’s, to observe work flow, record travel distances and the number of times a nurse had to leave a bedside to obtain medications or get supplies.

The management engineers created color coded “spaghetti” maps of the travel distances, by position, within a specific area. Individual departments were analyzed as well as the interaction and traffic flow between departments. Current-state mapping identified critical pathways for day-to-day operations, which were then utilized in computer simulations. That information, combined with other data such as medication flow and physician movement, was coordinated with staff input to determine the most efficient design scenarios.

“Considering future technology, such as new diagnostic equipment and the impact on patient flow, as well as the existence of a digital environment (instead of paper), is a big part of the process. So we often spend more on future-state mapping than current,” said Mr. Gandhi.

One significant change made as a result of the management engineering expertise, was to locate services closer to patient treatment areas, placing X-ray, CT and other ancillary equipment near the emergency room. Equipment was dedicated to outpatient and inpatient imaging, which served to reduce patient movement as compared to a more traditional centralized location that required more transfer time. The final design ultimately provided a 30 percent reduction in travel distances for staff and patients.

In addition to Lean, Six Sigma was used to decrease variability and defects, particularly in operational processes. One area in which Six Sigma has already provided cost-saving benefits is the emergency department (ED) billing process in Virtua’s existing facilities. Systemwide, the EDs were losing $1.5 million annually due to incorrectly assigned levels of acuity for patients at the time of registration. An improved process was initiated including standard definitions and continuing staff education. That improvement will be carried over to the completed greenfield facility.

Six designs were developed using Virtua’s Health’s processes. The design that was ultimately selected, was the one that combined the optimal design characteristics for the stated engineering objectives.

Nine teams help to advise Elmhurst Memorial Healthcare
Elmhurst Memorial Healthcare near Chicago is using a less formal approach to design its 259-bed replacement hospital, adjacent outpatient center and medical office building. Completion is planned for 2011.

“We have set out to improve processes for delivered care within a better overall building environment,” said Gail Warner, Assistant to the President for Strategic Planning and Special Projects at Elmhurst. “Management has been very metric driven to quantify important data,” Ms. Warner says. “We are identifying what information needs to be tracked and how it is to be gathered. We are constantly reviewing how this information can be used to develop process improvements.”

Elmhurst set up nine patient experience teams with the help of Hammes Company, comprised of staff and physicians defined by service lines. Each team looked at different scenarios, including what it is like to be an oncology patient, a surgery patient or an outpatient.

The result was the development of a series of “patient experience maps.” These maps focused on the critical issues of each group, including how a patient was moved to the department, what the experience was like, and how he/she was transitioned out of acute care.

SSM uses a combination of new approaches to develop their hospital design
SSM used management engineering techniques when it designed a replacement for its 158-bed St. Joseph Hospital in Kirkwood, Mo., a suburb of St Louis. St. Joseph used a step-by-step pre-design process, starting with “envisioning sessions” that included staff, physicians, and former patients who were asked to visualize what the hospital should look like in the future.

“Our aspiration was to re-examine the fundamental way in which healthcare is organized and delivered, and not just make incremental improvements,” said Robert Porter, Executive Vice President of Strategy and Development for SSM.

The Hammes Company project team worked with SSM staff management engineers and the hospital’s end users to analyze operations, develop current-state mapping, and outline the departmental workflows in a chart format. This was accomplished by interviews with patients and staff and photo-journaling. One of the main issues uncovered was the number of “workarounds,” a term describing instances when nurses took unplanned time away from patient care to gather necessary supplies, medicines and equipment.

To learn more about how to minimize “workarounds,” the staff visited a Boeing manufacturing plant and studied how that company utilized the Lean engineering process to efficiently supply necessary materials to assembly line employees.

A two-day learning lab brought in national design experts to work with the in-house design team and users such as patients, frontline staff and managers. The goal was to create a new approach to designing the hospital and its surrounding campus.

One effective concept developed was the “five-second rule”, which states that at least 90 percent of what a nurse needs in a patient’s room should be only five seconds away. This rule initiated design changes that replaced typical centralized nursing stations with nurse substations, keeping nurses much closer to patient rooms and necessary supplies and greatly increasing efficiency.

The staff also visited a Ritz Carlton Hotel and the local airport to observe their check-in processes. The lessons learned were incorporated as design changes to facilitate quicker check-ins and less wait time for patients and hospital staff. Computer-based patient slide cards were developed to reduce time spent keying in information.

Important conclusions drawn from each of the three hospitals
These three hospitals have come to many of the same conclusions about their buildings’ designs by utilizing different process management techniques:

  • They have all made the decision to segregate the inpatient and outpatient groups to improve flow efficiency and patient safety.
  • The information gathered from patient-experience mapping techniques was used to determine the optimal hospital environment to facilitate healing.
  • Supplies and equipment have been strategically relocated to increase RN efficiency.
  • Time-saving techniques for patient check-in and transportation have been instituted.

    “The transition of industrial engineering from the manufacturing sector to service industries and healthcare is accelerating,” says Hari Srihari. “Day-to-day cost cutting is a reality of modern healthcare. Management engineering must be a part of the existing healthcare building process to provide better results for everyone.”

    The author of this article, Harriett Linenberger, PhD, RN, is a Senior Operations Planner at Hammes Company. Prior to joining the organization, Ms. Linenberger served as Vice President of Patient Care Services and Chief Nursing Officer at two large hospitals. She has a Doctor of Philosophy in Nursing degree from Texas Woman’s University and completed her Master of Science degree in Nursing at the University of Texas, Health Science Center in Houston.

    For more information about the benefits of applying process engineering methods to hospital design and construction, please contact Harriett Linenberger at