Lean Service flows and building design: towards better integration

Lean Service flows and building design: towards better integration Ricardo Codinhoto Research Fellow at SCRI/HaCIRIC, The University of Salford, Maxwell Building, Room 412, M54WT, Salford, UK. Email: r.codinhoto@salford.ac.uk , Patricia Tzortzopoulos Academic Fellow at SCRI/HaCIRIC. Email: p.tzortzopoulos@salford.ac.uk , Mike Kagioglou Professor at The University of Salford, School of the Built Environment, Programme Director of SCRI/HaCIRIC. Email: m.kagioglou@salford.ac.uk, Lauri Koskela Professor at The University of Salford, School of the Built Environment. Email: l.j.koskela@salford.ac.uk Abstract To use service design as an input to the building design process is common practice in healthcare projects. In this manner, it is assumed that buildings can better fit its purpose if form follows function. The links between service and building design are strong in the way one can influence the development of the other. However, there is a lack of theory that explains these relationships. Therefore, the aim of this research is to better understand the links between service and building design by identifying how building design impacts on service delivery. The research design consists of identifying a set of existing UK measures of healthcare service efficiency and then categorising them against the 7 Flows framework. Furthermore, a literature review was conducted to identify how the 7 Flows are impacted by the design of the facility. Finally, a discussion of how changes in building design can impact on these flows and therefore service efficiency is presented. The main results of this article include a discussion about how the 7 flows framework developed for production can be applied to service operations. This paper also contributes to the development of theoretical understanding about the 7 flows framework as well as to better understand the relationships between service and building design. Consequently, to better understanding how space influence “production” flows, may, in practice, impact on the reduction of making-do. KEY WORDS Service design, building design, 7 flows, operational efficiency, healthcare Introduction The importance of appropriate infrastructure for healthcare delivery has been increasingly recognized. The pressure for improved performance of healthcare delivery stimulated the debate about how healthcare infrastructure responds to continuous changes caused by incessant modifications in healthcare policies, new ways of delivering healthcare services and emerging innovations impacting on both services and infrastructure. In this context, several authors have been claiming that concepts originally developed to improve efficiency and effectiveness of manufacturing processes can also be applied to improve healthcare service delivery. The improvement of operational efficiency has been discussed by several authors from myriad perspectives. Shingo (1989) for instance distinguishes production processes from operations and discusses the impact of operations flows on production processes. Production, from the process flow perspective has its focus on the series of transformations happening in an artifact being developed whereas the operations flows focus on the tasks being performed on the artifact during its development (Bertelsen et al., 2007). Hopp and Spearman (2001) analyses the relationship between variability and operational performance by means of Queueing Theory. Following the same principle, Koskela (2000) and Bertelsen et al., (2007) discuss the existence of 7 operational flows and they argue that improvement in production can be achieved by better understanding the characteristics of the different operations flows and their inter-relationships. From a different perspective, Tzortzopoulos et al., (2009) investigate how the design of facilities impact on operational efficiency. These authors conclude that very little is known about the relationships between infrastructure (building) design and operational efficiency. In this paper, a better understanding of the relationship between building design and operational efficiency is sought by means of discussing how the 7 Flows (Koskela, 2000) applies to service operations in the context of healthcare delivery. The research design consists of identifying a set of existing UK measures of healthcare service efficiency, decompose those measures and interrogate the relationship of the measures with the 7 flows framework. Thus, a discussion about which aspects of building design impact on these flows and therefore service operational efficiency is presented. Obvious issues such as lack of maintenance of the facility and disruption or failure on sub-systems (such as ventilation and M&E) are not considered in this discussion. Paper structure; Main findings Production and Operation Flows In construction, the use of our current understanding about the nature of flows and their interactions provides the basis for the theory of Construction Physics (Bertelsen et. al, 2006). This theory is inspired by Factory Physics (Hoop and Spearman, 2001) and has its foundations in Queueing Theory (Bertelsen et. al, 2006). The 7 flows, as presented by Koskela (2000) refer to the preconditions for the execution of construction tasks and include: construction design; components and materials; workers; equipment; space; connecting works; and external conditions. Unfortunately, the understanding of what Koskela (2000) means by each of these flows is subject to debate as the definition for some of the 7 flows is not presented. Moreover, the seven flows can be more than seven and this may cause confusion. For example, the flow of information and money (or cash flow) can be part of the flows in construction or in any other type of production. Bertelsen et al., (2006) argue that there is a relationship between construction flows, performance and variability. Their assumption is that the level of variability of each flow explains the performance of production systems, i.e. process flow’s performance increases as operational flow’s variability decrease. Following the processes and operations flows rationale, value-adding activities can only happen on the process flow axis whilst within the operation flow axis either necessary or non necessary non-adding-value activities occur. Therefore, process flow improvement can be achieved by reducing the time and or the number of necessary transformations for producing an artifact, as well as by increasing the reliability of the process through reduced variability in operations. Service processes and operations Flows Generally speaking, services relate to the work that a person or organization does for somebody. Services are not necessarily related to the development of a product and that means that understanding services as production and its division into processes and operations, as proposed by Shingo (1989), is not straight forward. Differently from manufacturing and construction, in service processes and operations flows the ontological view must include a subjective aspect. In other words, the way the customer perceives the service is extremely relevant and in the case of healthcare services, each patient (within the “production flow”) can react differently due to varied reasons. Services are also different from manufacturing and production because the may or may not involve both process flows and operations flows. For example, medical (clinical) services include a “healing process” flow axis” where a transformation in the health state of the patient occurs (namely the disappearance of the illness and its symptoms) and also an operations flow axis (e.g. catering and cleaning). On the other hand, posting services only include the operation flows dimension, i.e. there is not an intentional transformation happening in the item been transported. Another issue related to understanding services as production is that services are context specific. That means that the application of the 7 Flows concept, as presented by Koskela (2000), requires the abstraction of the flow concepts followed by their adaptation to contextual specificities. In the next section we discuss the issues related to adapting the 7 Flows to the healthcare service context. Healthcare services and the 7 Flows Koskela (2000) argues that construction is characterized by site production and that that characteristic has an impact on the production process. Following the same approach as Koskela we enquire: does site impact on services? Table 1 presents the issues related to site production in construction and its comparison with healthcare services are presented in Table 1. Site Production features Construction (Koskela, 2000) Healthcare Services 1. Site as a resource: The site is a necessary input resource for production The site is not a necessary input resource for production 2. Lack of shelter: There is usually little protection against elements or intrusion, rendering operations prone to interruptions Protection against elements and intrusion is given 3. Local resources conditions: local material and labour input often has to be used, potentially adding to uncertainty; other areas of uncertainty include site geology and other environmental factors No issues related to the use of local materials and labour. 4. Creating the production infrastructure: The production infrastructure (machines, manpower, etc.) has to be planned, procured and set up on site. The production infrastructure, once is planned, procured and set on site, tends to be kept for long periods of time. 5. Space needed by production (workstations move on the product): The spatial flow of workstations (teams) has to be coordinated (in contrast to a factory, where only material flow through workstations is planned). The spatial flow of workstations has to be coordinated in conjunction with the flow of people (workstation move to patients and patients move to workstations). As can be seen the items 1, 2, 3 are relatively more “stable” in services in comparison with construction. However, in item 4 the same stability cannot be found. In healthcare, infrastructure is to a great extent fixed whereas demand fluctuate randomly (reference) (some of the reasons include the fact that healthcare services are designed to consider elective and non-elective patients and the length of stay of in and out patients also vary). Moreover, item 5 brings an interesting point which relates to fact that whilst in manufacturing material flows through workstations, in construction and in healthcare services there are flows of material and people respectively as well as workstations. How does operation flows is impacted by facility design Flow Impact of building design on flows Information Way-finding: healthcare facilities are in general complex buildings that relies on information (usually in the format of signs) to guide patients through the facility. Inefficiencies in the information flow can cause confusion resulting in patient arriving latter to their appointments. Materials People Demand – impacts on the definition of the size of the facility and on the type of services to be provided and therefore on the type of necessary equipment. Length of stay Equipment Elective and Non-elective-care wayfinding Clinical services there are certain times where the patient flows and there are certain times where the process flows. Front and back office activities Discussion The site production… right thing to move primary care services from secondary care so to reduce… Conclusions Findings Theoretical discussion regarding which aspects of service are influenced by the facility Conclusions References PAGE 4