As Cleveland’s public hospital, The MetroHealth System has long served the city’s most underserved population. However, its existing campus, which includes a variety of buildings constructed between 1912 and 2004 and totaling more than 2 million square feet, has outlived its usefulness. The facility can no longer accommodate fast-evolving advancements in technology and patient care.

To address this reality, the organization is building a new 11-story acute care hospital on its 52-acre site, which is scheduled for completion by 2022. In partnership with HGA (Milwaukee), the master architect and engineering firm responsible for planning, design, and delivery on the project, the system is also working to innovate planning, design, and construction.

The goal is to create a healthcare facility that’s dynamic rather than static, resulting in a set of best practices that use a Lean philosophy and “process-neutral” design approach.

“Process-neutral design is achieved by delivering maximum flexibility now and 50 years into the future,” says Walter Jones, senior vice president of campus transformation at MetroHealth. Traditionally, Lean methodology seeks to eliminate waste by focusing on the way care is delivered today and improving upon it. Broadening Lean to include potential future states, the concept of process neutral looks toward the number of different ways care might be provided going forward, as well.

The team’s challenge, then, was to design a high-performing hospital that supports present needs without restricting the building’s ability to respond to what comes next.

Getting started
The first step in this process was to assemble an internal group of thought leaders, called the Innovation Team or “I-Team,” with core competencies in such key areas as space optimization, Lean operational improvement, evidence-based design, environmental sociology, and technology. Together, they provided unique perspectives and challenged conventional thinking.

The I-Team generated various concepts and schemes about the future in their respective areas of expertise and collaborated on how to support them in the design. For example, MetroHealth is interested in using automated guided vehicles (AGVs) in the new hospital. To provide flexibility, the team was challenged to create the infrastructure in a process-neutral way so that the facility can perform with or without these vehicles. The solution was to incorporate space directly off supply corridors for robot loading, charging, drop-off, and parking, with spaces placed and sized to support either manual or robot delivery.

Through intensive pre-design workshops, the team also examined space utilization to identify how to quickly adapt rooms to new delivery methods and processes, focusing on eliminating over-specialized spaces. Team members looked for synergies between clinical service areas and operations to think more universally about design, grouping similar work functions with similar work spaces to create a series of clinical platforms. One such example is a 90-patient, short-stay platform developed to accommodate all surgical, procedural, and medical observation patients as well as the post-anesthesia care unit. By combining these functions in one space, the design eliminates redundancies related to time-of-day and day-of-week utilization swings, resulting in approximately 15 percent fewer treatment spaces. However, to design for the highest need, some spaces are oversized by as much as 10 percent to create flexibility.

Brent Peterson, senior industrial engineer at HGA, says staff input was critical to Lean thinking during this process. Front-line providers have insight that informs realistic variation, which makes the model more believable and less theoretical.

Layering on experience
Universal concepts also must support a great patient experience, so in collaboration with MetroHealth’s in-house Patient and Family Advisory Council, HGA reviewed extensive surveys and interviews that were conducted in 2014 to define the ideal customer experience. HGA benchmarked the narratives against best practices to identify gaps, then took this information and applied it to the patient experience journey across the proposed universal platforms. “Any opportunity to create Lean operational savings by eliminating waste in the process must be in service to the customer experience, because value is defined by what the customer values,” says Kevin Ortner, director of transformation operations and transition at MetroHealth. “Otherwise, you’re just making it less expensive, not necessarily better.”

The I-Team analyzed suggested best practices using a three-step process: defining the problem, brainstorming seven ways to solve the problem, and analyzing the solutions via quantitative methods (such as time and motion studies or return on investment) and qualitative judgments about what would best enable the ultimate patient experience. On difficult or controversial issues, the team members used force ranking exercises, which involve establishing evaluation criteria, individually voting on what’s most important, and building a consensus. This process stimulated meaningful conversation and helped the team arrive at decisions.

One patient and family need identified from this process was access to information and services. To address this, the team created a concierge service space for patients and families in a planned Patient and Family Center, which serves as a one-stop hub for information on area amenities (restaurants, hotels, transportation); services such as home care; education and information on therapy and support groups; and connections to other patients and care teams. The introduction of this shared space supports Lean and universal process-neutral philosophies and allows the reduction of dedicated or specialized education or waiting areas on patient units.

The long term
As the project progressed through design, the team continued to consider how design concepts must change to support the universal concepts being implemented. This ultimately affected every system in the building, and careful coordination across each piece was necessary.

For example, a 250-bed universal med/surg/ICU platform was created that can flex over time, based on changes in patient acuity and service volumes. The building itself and its infrastructure exhibit careful attention to structural grid spacing and vertical floor-to-floor height to anticipate unknown future technologies. Spaces are zoned by aligning mechanical and electrical infrastructure areas as well as aligning clinical and support areas. This provides open floor plates that can be adapted to future platforms.

In departments such as lab, pharmacy, and staff areas, demountable partitions are used to deliver adaptability for changing technology. Additionally, clean/soiled/waste flows and spaces are programmed and designed to support the desired future use of AGVs.

The resulting hospital elevates MetroHealth’s best practices; provides a technologically advanced and compassionate patient-care experience; and creates a cost-effective, sustainable, and patient-focused hospital. This transformation will support MetroHealth’s ongoing mission in the Cleveland community and enable it to adjust to the rapidly evolving ways that healthcare is being delivered for many years to come.

Kurt Spiering, FAIA, ACHA, is a principal and healthcare market sector leader at HGA (Milwaukee). He can be reached at Mark Bultman, associate AIA, is a principal at HGA. He can be reached at