September 19, 2017

In our healthcare projects, we employ a design framework known as value-added design (VAD), which aims to drive value in six key areas: patient safety; operational efficiency; integration of technology; adaptability and resiliency; sustainability; and evidence-based design for a better human experience. What I like about this concept is that it incorporates Lean principles through the focus on operational efficiencies, while allowing us to strive for more than just an operationally efficient facility.

In today’s post, I examine how Gresham Smith’s renovation of the Whitaker Clinic of UAB Hospital in Birmingham revealed an additional benefit of our VAD process with its associated Lean principles—the ability to bring people together. Along with unifying our team, it also built consensus among UAB physicians and staff.


Lean Processes for Consensus-Building

When the University of Alabama Health Services Foundation decided to relocate the primary care clinics they sought an opportunity to evolve and enhance their care practice. Along with our principal contacts, we were fortunate to work hand in hand with UAB’s internal Lean advocates, their Performance Engineering group. As the current clinic design was no longer serving the university’s needs, our team was tasked with developing a new prototype clinic focused on increasing room utilization, flexibility, and a collaborative environment.

Our first steps were analyzing UAB’s current practice data to garner a deeper understanding of their existing operations. Through focused design charrettes that comprised a diverse group of physicians, nurses and other staff members, we formed a collaborative framework to exchange ideas.

Starting with a clean slate, and existing conditions, we took a step-by-step approach, designing from the patient and client perspective. Together, we developed several layouts, and as “homework” asked the team to collect comments and feedback from staff for review in the next charrette.

Through this process, we were ultimately creating advocates who would then champion the design and take ownership. In this way, critical work was being done internally in problem-solving and evolving both their operational model and building consensus. While, at first, the charrette group may have been hesitant about some of the upcoming changes, the Lean process continued to guide us with data-backed recommendations.

In our charrettes, we tested different relationships and concepts and ran them through simulation modeling, using median times and data previously collected from their clinics. Design concept to evaluation to refinement became a cyclical process. We weren’t just designing—we were crafting processes and operations that dovetailed with the architecture to create a prototype clinic. The parallel efforts of charrettes, mock-ups, and simulation results were critical to gaining buy-in and expediting decision-making.


The charrette group evaluated and provided feedback on various layouts.


Value-Added and Lean Design Improvements

We took a methodical approach through Lean design and VAD to address client objectives. Their existing clinics were closed-in, lacking access to daylight as well as views to the outside for wayfinding. Previously, the clinics were siloed and lacked flexibility, which drove down exam room utilization.

The new orientation, with public/waiting areas pushed to the building’s perimeter, and corridors aligned to allow light to penetrate deep into the facility, provides a sense of openness. A contiguous staff corridor allows for connectivity between clinics, shared back-of-house functions, and the ability for physicians to work out of multiple clinics.

Simulation modeling proved our preconceptions wrong. We all thought that a separate triage space would improve through-put and be more efficient. However, the data results could not have been more stark. Each time a patient was moved, it added time to their visit, the physician’s day became longer, and it reduced patient volumes and room utilization.

Comparing design options indicated that performing triage in the exams drastically shortened the length of stay, increased face time with the staff, and improved staff efficiency. By focusing on three of our key VAD drivers – technology integration, enhanced human experience, and operational efficiencies – we shifted the mechanics of how a physician and patient occupy an exam room.


Simulations enabled the team to make decisions backed by practice data.


Mock-ups were useful in streamlining the typical exam room. We replaced the traditional swing door with barn-type sliding doors, swapped out stationary cabinets with a counter and mobile cart, and combined the patient chair, scale, and exam table into one piece of equipment to save space in the room.

The exam chair/table with a built-in scale eliminated moving the patient within the room, which also saved time. The new exam room allows physicians or the care team to sit across from the patient and maintain face time throughout the exam, further augmenting the patient experience and eliminating barriers between provider and patient.

Optimized clinic layout improves utilization and operationally efficient exam rooms enhance the patient experience.


Process and Design

Not only did Lean principles and value-added design solve many of the business and design challenges associated with the renovation, our processes themselves were imperative to aligning our team and gaining resident support. Perhaps the most important element was being able to move beyond “our hunch” and provide specifics, such as how much time a design would save the practice using actual practice data. This took the emotions out of the design process and built consensus much faster.

Ultimately, our VAD framework with applied Lean principles resulted in improved operational efficiencies and an entirely new practice model that delivered a better human experience, and was supported by both clinicians and staff.