Many healthcare systems today rely on facility prototypes to deliver faster, more efficient new building projects. The complexity of modern hospitals is a driving factor in this trend. When difficult design challenges are addressed and resolved in one project, the prototype approach helps the healthcare system repeat and even improve on these solutions in subsequent projects.

Lean design can work hand in hand to further enhance the benefits of the prototype approach. An example is Kindred Healthcare’s 52-bed stand-alone rehabilitation facility on the campus of Palomar Medical Center Escondido in California. Located in suburban San Diego, the Palomar Health Rehabilitation Institute broke ground in August 2019 and is expected to be complete in late 2020. The healthcare network’s development strategy dictates that the prototype hospital approach that delivers the best value and outcomes for its patients, when combined with Lean design principles, results in a more efficient, cost-effective building product. The facility design for its latest project is based on a prototype hospital first designed and constructed by the Kentucky-based healthcare system in 2008 and 2009 and since used on approximately 35 other facilities.

Applying Lean principles

The Lean Construction Institute (LCI), an association of owners, architecture and engineering firms, general contractors, and trade contractors, defines Lean as “a culture of respect and continuous improvement aimed at creating more value for the customer while identifying and eliminating waste.” LCI outlines six primary Lean tenets, each of which applies to how Lean design complements the prototype hospital concept.

1. Optimize the whole, not the parts. One of the central themes of Lean is for disparate members of the team to constantly consider how their individual actions influence other members. In this way, they can optimize not only their own contribution to the project, but that of other team members as well. Thus, the entire project is better.

On Kindred Palomar, the project team relied heavily on pull planning and routine check-ins with the full team to review schedule and task completion. Pull planning is a collaborative approach that starts by mapping project milestones, such as 25 percent design, and works backward from the completion date through the steps that lead to those milestones. Early recognition of the critical steps necessary to complete the project help reveal areas of concern that one or more team members may have that others are unaware of. This gives each team member an opportunity to potentially change their process to help someone else perform more efficiently. These “all hands on deck” meetings also allow for different perspectives to be aired, and for those with certain expertise to offer their insight to the entire team relating to the project as a whole.

2. Remove waste. Lean encourages team members to see and reduce waste in all aspects of a project. Similar to optimizing the whole, waste removal benefits from experiences gained during earlier prototype projects. Decisions come faster, and the team spends more time improving the design and less time resolving problems and putting out proverbial fires.

On Kindred Palomar, lead contractor McCarthy Building Cos. identified systems that could be prefabricated, such as piping and conduit assemblies, which offered greater cost certainty, faster procurement and build time, fewer change orders, sooner availability for users, better quality, and greater return on investment. Over the course of multiple projects, this type of efficiency increases with well-organized construction sequencing and planning.

3. Focus on process and flow. Another primary component of Lean is ensuring that there are smooth, unimpeded handoffs and reliable processes from project beginning to end. Clearly stated commitments, made and kept, are key to efficient process and flow on any project. Prototypes amplify this benefit by providing a proven roadmap on how the process and flow can work (or may not work) most effectively.

Conflict resolution is also critical to Lean project performance. For Kindred Palomar, the team used “A3,” a Lean staple that keeps discussion around major issues focused and condensed, traditionally by limiting the discussion to a single sheet of A3-size paper. Within a single-page document, the team identifies serious concerns and collectively seeks solutions. The A3 document becomes a record for future projects, aiding continuous improvement by detailing the decision-making process.

Building orientation was an early issue with Kindred Palomar and was the subject of the first A3. The document allowed all relevant team members to weigh in and express their thoughts and concerns. Within three days, a preferred solution was identified and moved through the pipeline to the owner for consideration. For prototypes, an added value is that all disagreements and differing views are institutionalized and available to consult in the future.

4. Prioritize respect for people. LCI calls respect for people a “bedrock concept” of Lean. On any type of team, respecting and trusting teammates is a key to realizing the full benefits of the ultimate goal. Continuity helps to build trust in people and in processes. This is one reason that prototype hospital owners and developers often carry some or all parts of the same team from location to location, rather than relying solely on local architects, engineers, designers and contractors.

Kindred brings its trusted project team members into its inner circle; they aren’t just given instructions and sent on their way. Prior to beginning the Palomar project, members of the project team met with Kindred’s leadership at their headquarters in Nashville, Tenn., and toured a late-model prototype that had been recently completed in Tacoma, Wash.

5. Generate value. Lean dictates that to deliver value, one must understand what value means to the user. The LCI encourages capturing the value proposition as defined by the client and users, then writing it down and keeping it top of mind and in plain sight throughout the project. This can be as subtle as a single-sentence mission statement shared by the team, or as prominent as posting large signs with a bulleted wish list all over the worksite.

Kindred uses a post-closeout assessment policy to help define value in its network of prototype hospitals. By soliciting feedback from users when a project is completed, and sharing the information with the project team—on both current and future projects—Kindred restates and refines what value means to the user.

6. Ensure continuous improvement. This tenet has a dual meaning, including both improving workflow on an ongoing project and making the next project better than the last. Continuous improvement is where the rubber meets the road in prototype hospital projects. For example, constraint logs, in which all team members identify obstacles to success and possible ways to resolve them, are a Lean tool used to ensure continuous improvement while a project is still underway. Another is the “plan-do-check-adjust” (PDCA) Lean technique, which is essentially the scientific concept of developing a hypothesis and then testing its workability.

Kindred Healthcare uses the PDCA model to apply lessons learned from facilities under construction or recently completed to subsequent projects. In one recent example, the team discovered that the headwall material required splicing. This let the team (on both the existing project and on subsequent prototypes) that it’s critical to ensure that the headwall material is ordered with the correct lengths to cover the full headwall.

An example of continuous improvement on the Kindred Palomar project is an innovation made to the rehabilitation gym. When therapists and other users commented on poor sight lines from the staff work area to the part of the room where patients independently underwent physical therapy, the team opened up the floor plan to accommodate greater visibility across all areas of the gym.

Prototype as a starting point

It’s important to recognize that “prototype” does not mean “cookie-cutter.” While many decisions related to layout and materials are pre-determined by the prototype, the need for creative design remains. In fact, unique design options can be considered more carefully because basic planning elements take less time. The prototype is simply a starting point.

For example, site circulation and sun orientation require early input. Answering the question of how the building will be seen from the outside can help differentiate a prototype hospital from its sister facilities, while maintaining the prototype design’s efficiencies.

Each facility has unique exterior and interior design elements, along with materials specific to its surroundings. Some are more suited to modern exterior finishes that incorporate metal panels or glass. In the case of Kindred Palomar, stone and fiber cement were widely incorporated to complement the adjacent Palomar Hospital and fit in with the campus aesthetics. Every facility deserves a design that fits with its community, gives users a sense of comfort, and makes sense in its surroundings, including prototypes. 

Room to grow

With each completed prototype hospital, satisfaction and confidence grow among owners, developers, design professionals, and users. This accelerates decision-making, minimizes changes and delays, and lowers costs. As processes are better-defined and understood, project teams shrink in size and grow in productivity.

Prototype hospitals, combined with the Lean approach, can offer outstanding opportunities for continuous improvement, reduced waste, and greater efficiencies. They can also result in a creative, beautiful design that suits the community and functions exceptionally well. For this to happen, the project team needs to ensure that it preserves opportunities for innovation, utilizes lessons learned, adapts to unique circumstances, and adequately addresses community needs and requirements.

Joe Lowe, AIA, is office leader and an associate with Taylor Design (San Diego, Calif.). He can be reached at Steve Van Dyke is vice president, healthcare, for McCarthy Building Cos. (San Diego, CA). He can be reached at Mark Toothacre is president and partner with PMB (San Diego). He can be reached at