The subject of ambulatory care setting continues to grow and provides a much needed resource for urgent care, primary care and speciality practices. Ambulatory care centres can provide better access for patients and increase efficiencies in healthcare arena. Design changes to these centres can be impacted with lean operational planning. Lean is centred on what adds value and reduces waste. Each centre has to define ‘value’ to understand their vision. Once defined, it allows the ability to seek ideas and solutions that add value and an environment that will continue to form and improve the system.
Lean Ambulatory Care Methodology
In the ambulatory care setting, the lean process should be a very interactive and participatory process. Meetings should involve senior leadership, physicians, managers and clinical staff representation including ancillary services that may be a part of the facility such as registration, laboratory, medical imaging, materials management, environmental services, pharmacy, and other services.
Assessing space needs should be derived from sound prediction techniques and tools. Key rooms should be determined using operational variables that are established with the centre’s leadership group.
A lean overview with users will identify the customer, what the customer values, and what are considered eight deadly wastes of healthcare. Lean concepts identify value added time and reduce non-value added time. This allows for a visioning of the project and helps find operational and design solutions to create an environment that can continuously adapt to change and constantly improve. Guiding principles or project goals are established with a vision that would allow the team to test every decision they make whenever questions about doing or not doing something arise.. The lean operational planning and the development of the vision, guiding principles/goals are intended to maximise the flexibility, effectiveness, and life cycle of the building. They will help shape future decisions regarding new programmes and emerging technologies.
Lean current state process mapping depicts current operations and workflow for processing patients through the ambulatory care centre. Value Stream Maps (VSM) can also be created to demonstrate value-added and non-added-value time. Each step can be mapped resulting in opportunities for Kaizen moments or improvement that can be depicted on the map as ‘starburst’.
Lean future state process mapping is employed to rethink and visualise the ideal process for every operational task. The future state map will depict the desired methods for operating the centre. Process analysis uses data process steps to evaluate flow of staff and patients. This lean methodology process generates diagrams that document preferred processes for the seven flows of healthcare. Diagrams such as ‘swim lane’ are just an example of what can be done. Identification of process changes that could be implemented in the existing facility as well as the new facility is an added bonus in lean planning.
The seven flows of healthcare are patient flow, staff flow, supply flow, equipment/instrument flow, lab flow, medication flow and information flow. Spaghetti diagrams can be extremely helpful in mapping the seven flows. These seven flows can be identified both vertically and horizontally throughout the facility.
A ‘kit of parts’ is another tool in the lean toolbox that can be designed to allow users to actually see the many programmed rooms and spaces for creating adjacencies. The users can break into groups and organise individual pieces and then present back to each other their designs. Clinic modular adjacencies can be created on paper for the users to begin looking at the placement of clinics or support spaces within the actual building and on the floors.
Observational studies of existing clinics or ambulatory care centre sallow users to ‘Go to the Gemba’ and understand how work happens in the centres, especially newer facilities.
Physical mock-ups can be developed from a module in a clinic setting, an exam room, a procedure room, or other spaces for the users to visualise and possibly standardise spaces being designed. If the workload in one clinic module increases, there is the capacity to flex over due to the standardised room or module concept accommodating change in clinic programmes. The clinic module can also have support areas within which can be designed to be manipulated for meeting the needs of a specific clinic. This helps users to understand their space and in reviewing for functionality and cost-effectiveness. Several scenarios can be played out in these mock-up spaces.
Open houses with designated stations led by the users, will give access to the staff and providers who are not a part of user meetings to see the developments and provide feedback.