Efficiency equals profitability

Clinical design is ever evolving, with influences such as insurance reimbursement, patient expectations, administrative migration, and regulatory guidelines. These influences increase the complexity of the overall care system, and historically have created waste and interruptions of flow within the core processes of a clinic.

When designing a clinic it is important to provide a safe, private, comfortable environment to all patients, while maintaining maximum efficiency in clinical operations. Efficiency equals profitability and that efficiency must be analyzed with an intense focus on reducing waste and improving flow. Consumables, travel distances, throughput times, or perhaps most notably, talent, should all be taken into consideration, yet these are often ignored when it comes to clinic design. That’s where LEAN is very useful.

The LEAN process

According to the LEAN Enterprise Institute, LEAN is most simply defined as “creating more value for customers with fewer resources.” Originally developed by the Toyota Motor Company, LEAN was transferred from manufacturing to the service industry, which changed management’s focus to “optimizing the flow of products and services through entire value streams that flow horizontally across technologies, assets, and departments to customers.” Once designers start to observe the flow, they immediately see interruptions in the flow caused by waste. The concept of “waste” in LEAN is defined by the opposite of what customers value. For instance, how many customers consider it a value to wait longer than 30 minutes in a waiting room or walk more than 100 feet to interact with a care provider? If a customer is not willing to pay for something because it is not of value to them, then the supplier must rationalize it as a form of waste and determine how to minimize or remove it from their process. It is in this regard that the value of using the LEAN process in health care design and delivery becomes immediately evident.

LEAN is most simply defined as “creating more value for customers with fewer resources.” 

—LEAN Enterprise Institute

Clinic design and value-based reimbursement

Two hot-button issues to surface over the past couple of years are tied to legislative changes in reimbursement and health care staffing. Legislation mandated that reimbursements be based on patient satisfaction and effectiveness of treatment. Reductions in reimbursement levels have strengthened the incentive to maximize staff efficiency and patient throughput. Effective clinic design can both increase patient satisfaction through reduced wait and travel times, and maximize throughput by leveraging adjacencies and technology.

In addition, several recent industry surveys have indicated that the biggest challenge facing health care administrators is shifting their concern from “behind-the-scenes” financial issues to meeting the needs of skilled front-line staff and licensed and registered nurses. It’s important to consider how to attract, compensate, and retain top talent. With expenses always a concern and heavily scrutinized, paying staff at a higher rate is not always possible. Effective clinic design creates a more desirable working environment, but taking increased patient throughput and satisfaction in mind may ultimately lead to higher revenue, lower staffing requirements, and greater compensation possibilities.

All of this points to the cohesive goal of designing and constructing patient care facilities that alter how we look at traditional practice methods and emphasize a new approach. This is how architects and health care providers can collaborate to make things better.

Patient-centered care models

The medical home model of patient care, where patients and staff enter exam rooms through separate doors on opposite sides of the room, is an emerging trend in outpatient clinic design. In this model, there is a natural separation of “on-stage” and “off-stage” areas, so patients no longer travel past nursing stations and sensitive information on their way to the exam room.

Taking this medical home model a step further, Altru Health System recently opened an orthopedic clinic at the Professional Center in Grand Forks that incorporates wearable technology in the clinic. This technology allows patients to find their way to the exam room on their own, and alerts staff when a room is occupied. This eliminates the need for a nurse to escort patients to exam rooms, freeing up their time for more skilled tasks. It also eliminates the oversized waiting room and pre-appointment waiting—both points of patient dissatisfaction. Reducing waiting room size, replacing private physician offices with modular workstations and shared staff bullpens frees up extra clinic space. This enables the clinic to add more revenue-generating space and further enhance efficiency in throughput and reducing waiting.

Analyzing the design post-occupancy

We were given the unique opportunity as the designer of Altru’s orthopedic clinic to perform a post-occupancy validation from a LEAN waste and flow perspective. Leveraging our expertise in LEAN manufacturing, we spent time reviewing the layout for potential opportunities to reduce waste and increase flow. We followed that up with a Gemba walk, which was a series of informational tours and interviews with key participants about the operational space of the final facility to collect data regarding the design’s impact on key efficiency indicators.

To achieve this critical measurement, a specific value stream process, identified as “New Patient,” was defined using the current state of the process (e.g., old layout) and the future state of the process (e.g., the new medical home model). A LEAN tool for visual creation of actual flow, called spaghetti diagramming, was utilized to map the steps and stops of patients as they proceeded through the current and future states of the specific New Patient value stream process.

Design Impact on Travel Distances

In comparison to the previous operation, patients in a typical New-Patient Process saw an 11 percent reduction in travel, which may not seem significant until you look at it from the perspective of a 100 New Patient cycles per day, where that reduction equals upwards of 26 miles of reduced travel distance in just one month.

When this same comparison is done from a staff nursing perspective, the results address the hot button issues identified by administrators as a top priority regarding staff fatigue and retention.

In comparison to the previous operation, nursing staff in a typical New-Patient Process saw an 81 percent reduction in travel distance and the elimination of at least two trips (e.g., transport waste). Looking at over 100 New Patient cycles per day, the reduction equals upwards of 53 less miles traveled per month and almost 500 hours of eliminated transport time for the nursing staff with a 50 percent reduction in trips required for a month’s worth of New Patient cycles.

Results and next steps

The results in terms of patient and staff satisfaction are not scientific at this time, but those who voluntarily answered our queries, were overwhelmingly positive about the new clinic layout. Providing a space where staff feel they can be effective and thrive is a low-cost way to attract and motivate talent. As the familiarity with the space grows, and the immense data we are collecting is analyzed, these efficiencies could likely contribute to increased revenue, staffing reductions, or both.

Additional LEAN assessments and tools could further refine the clinical process, and are being integrated more and more each day. Inventory tracking systems, specialty casework that can be accessed from both on-stage during consultation and off-stage by non-providers, and long-term data collection and analytics through the patient tracking software all provide further opportunities and insight when designing clinics in the future.

Architects and health care providers can collaborate to make things better.


Going forward, it is important to view the architecture and design factors that go into truly efficient and effective clinical operation through a LEAN lens. LEAN-based design can allow for a reduction in footprint (or more revenue-generating space within a pre-determined footprint), reduced throughput times (meaning more patient cycles per day), increased patient and staff satisfaction, and increased profits. Well directed capital investments can also be offset by reduced staffing requirements or increased revenue generation from the more efficient use of resources. Obviously, there is much to be gained from applying LEAN principles to the design and operation of health care spaces where our clients provide important, and often critical, services to patients in our communities.


This article was published in the Summer 2016 issue of NDHA Insight, the December 2016 issue of MN Physician, and Volume 32, Edition 12 of Care Providers of Minnesota’s Action Newsletter