Hospitals And Industrial Engineering

Hospitals and health care is big business in Nashville and Middle Tennessee. One of the newest trends in construction of facilities in the industry is the impact of industrial engineering.  

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 management engineering, or process engineering within health care, it is comprised of many techniques functioning together.

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.

 “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,” said Hari Srihari, Ph D., chairman of systems science and industrial engineering, State University of New York at Binghamton. “As our economy spends more money on health care, both in absolute terms and relative terms, it is becoming extremely important to streamline our health systems and delivery utilizing these methods,” he added.

 “The transition of industrial engineering from the manufacturing sector to service industries and health care is accelerating,” Srihari continued. The techniques are becoming increasing 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.

 “You get a better building out of it, because it improves the efficiency of health care services and increases patient satisfaction,” said Rich Galling, President of the health care development and management firm Hammes Company, headquartered in Brookfield, Wisconsin.

According to Galling, whose company is involved in dozens of health care construction projects across the country, 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, but particularly in personnel, equipment and supply utilization.

 “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,” Galling said.  “For example, engineering techniques optimize facility functionality so the facility runs with the most efficient number of FTEs,” he added.

Some of the hospital groups that have used or are using management engineering in their pre-design and design processes of new medical facilities are New Jersey-based Virtua Health, SSM Healthcare of St. Louis, and Elmhurst Memorial Healthcare, which is located near Chicago.

Virtua, for instance, has a formalized approach utilizing many methods and techniques, including Lean and Six Sigma. It has an in-house staff of management engineers headed up by Tejas Gandhi, Director of management engineering.

 “Historically, operational processes were tailored to the facility’s design, but this approach hurts health care in terms of future staffing and throughput,” said 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.

Before designing its new Greenfield, N.J. campus, 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.

Lean was used to find and eliminate waste. In a hospital one of the biggest wastes is the time spent moving patients, which taps the valuable resource of staff time. Lean helps to systematize waste removal by working with special time-saving techniques.

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

The management engineers then took that information and 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 sometimes more time is actually spent on future-state-mapping rather than current,” said Gandhi.

Six designs were developed. Ultimately one design was selected that combined the optimal design characteristics for the stated engineering objectives.

One significant change as a result of the design was locating services closer to patient treatment areas, such as 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 % reduction in travel distances for staff and patients, Gandhi noted.

In addition to Lean, Gandhi also pointed out that 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. System wide, 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.

 “We took longer than the typical process, because management felt that the time invested up-front would be well spent given the 40-year life expectancy of the building,” Gandhi added.

Other health care systems are also benefiting from the techniques.  SSM is replacing its St. Joseph Hospital of Kirkwood, a suburb of St Louis, with a $236 million, 158-bed campus using management engineering techniques.  The medical complex is expected to open in 2008.

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

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, Porter explained. 

These sessions were followed by a two-day learning lab, which 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.

Management engineers were hired to work with the hospital staff and the Hammes Company team (which has been overseeing development and construction of the new facility) 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 increase in “workarounds,” meaning nurses had to take unplanned time away from patient care to gather necessary supplies, medicines and equipment.

To learn more about the process of minimizing “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.

One effective solution developed was the “five-second rule,” where at least 90 % of what a nurse needs in a patient’s room is only five seconds away.  This rule facilitated design changes replacing typical centralized nursing stations with nurse substations, thus locating nurses much closer to patient rooms and necessary supplies.

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

Elmhurst Memorial Healthcare near Chicago is using a less formal approach to design its 240-bed replacement hospital, adjacent outpatient center and medical office building.  Construction will begin at the end of 2007 and completion is planned for 2010.

 “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. Like the other hospitals, Elmhurst’s primary focus is on the patient experience.

 “Management has been very metric driven to quantify important data,” Warner said, “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.”

To that end, Elmhurst and Hammes Company set up nine patient experience teams, comprised of staff and physicians defined by service lines. They each took different perspectives, 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. 

All three of these hospitals have come to many of the same conclusions about their buildings’ designs.  For example, they are all segregating inpatients from outpatients to improve flow efficiency and patient safety as well as address the unique needs of those patient types. 

Patient-experience-mapping techniques were also utilized by the hospitals to determine the optimal hospital environment that facilitates healing. Along with patient preference, studies have shown that rooms with the most daylight and views of the natural environment, and those that accommodate family involvement result in shorter patient stays and less medication. Architects were challenged to re-configure room spaces and window placement when developing the overall designs.

By utilizing these proven techniques from industrial engineering, hospitals can be more operationally effectual, improve the patient and staff experiences, and have a positive financial impact.

As Srihari concluded, “With day-to-day-cost cutting an important part of the modern health care philosophy, management engineering must be a part of the existing health care building process to provide better results for everyone.”