Lean design improves both health-care facilities and processes: a literature review

This article presents a literature review of the challenges and possibilities for Lean design in modern health-care facilities. Many of today's health-care facilities are in dire need of renovation since limited financial resources among health-care demand improved work process efficiency, safety and employee well-being. Lean philosophy has been successfully implemented into hospitals with up-and-running hospital processes, but has not been thoroughly tested as a design methodology. The principles of Lean do not contradict with user-centric, participatory or ergonomic design approaches and thus the possibilities of using Lean as a complementary design methodology to the aforementioned approaches are discussed in this article. Lean fundamentals are also useful when dealing with change management issues. Lean offers a fundamentally solid ideology and a wide range of tools – many of which seem fitting to solve several urgent design problems in today's health-care design.


Background
Health-care practitioners' work is physically and psychologically intense. Due to an aging population structure in the developed countries, it is important to ensure health-care workers maintain good physical and mental health. This can be accomplished by creating a good work environment that promotes wellness, improves coping with stress and maintains one's ability to work (Smith and Sainfort 1989;Ulrich 1991). By improving physical environmental dimensions of a healthcare facility (air quality, acoustics, lighting, seating arrangements, etc.), significant effects on staff health and work efficiency could be gained (Ulrich et al. 2004;Ayas, Eklund, and Ishihara 2008;Salonen et al. 2013). A well-designed hospital increases users' well-being, satisfaction, patient safety, expedites patient recovery rates, makes the space efficient, effective, productive, user friendly and comfortable, while reducing medical errors, hospital acquired infections, staff stress and injuries (Ulrich 1999;Gesler et al. 2004;Gluck 2007;Ulrich et al. 2008;Poldma 2009;Rechel, Buchan, and McKee 2009;Haron, Hamid, and Talib 2012;Mourshed and Zhao 2012).
With the financial constraints among today's health care, improved cost efficiency is demanded. Health-care processes are changing, which also creates need for new facility design. Many health-care facilities are outdated and require major renovations because they have a tendency to create delays that may negatively impact patient safety and work efficiency (Mullaney 2010). Most hospital designs are complex and possess an abundance of interrelated functions that must accommodate the constant movement of people, equipment and supplies throughout its structure (Haron, Hamid, and Talib 2012). Poorly designed and crowded hospital work spaces are common and may cause fatigue, stress and burnout and compromise patient safety by disrupting the staff's work performance, quality of care and lead to an increased number of medication errors (Gluck 2007;Chaudhury, Mahmood, and Valente 2009;Aiken et al. 2011;Mahmood, Chaudhury, and Valente 2011). Design modifications at later stages of a hospital building's lifecycle are expensive and difficult to achieve (Mourshed and Zhao 2012). In the long run, building and maintaining a new, well-designed health-care facility may even become cheaper than maintenance of an outdated one due to, e.g. new HVAC (heating, ventilation, and air conditioning) systems, which significantly improve energy savings (Bizzarri and Morini 2006;Vanhoudt et al. 2011;Ascione et al. 2013;Reijula et al. 2013).
Lean is a comprehensive management philosophy attempting to create more value (e.g. direct care) for the customer (patient) by removing waste (everything besides value-creating activity) in the work process. Lean principles can have a dramatic effect on improving processes and outcomes, reducing cost and cycle times and increasing patient and staff satisfaction (Mullaney 2010). Lean philosophy is known for improving the efficiency and quality of health-care processes but has also enhanced work environments (Martin, Hogg, and Mackay 2013). It has become popular among health care and been implemented successfully into a growing number of health-care facilities worldwide (Jones and Mitchell 2006;Ben-Tovim et al. 2007;Nelson-Peterson and Leppa 2007). However, some mixed results about the health effects of Lean work processes have also been presented (Koukolaki 2014).
This article is a literature review of over 100 research articles conducted regarding Lean and health-care facility design. The aim of this article is to explain the basic Lean fundamentals and to consider, whether it can be effectively utilized alongside user-centric and participatory health-care facility design. The benefits of Lean in managing organizational change in health care are also discussed. Additionally, some important ergonomic design factors for Lean facility design are discussed. Moreover, a few vital challenges and possibilities of using Lean design approach to enhance health care are discussed in this article.

Lean fundamentals
When 'Lean thinking' is implemented into a health-care facility, it should be utilized throughout the entire organization; knowledge rippling from senior executives to all workers in different levels of the hospital. This, top-down topology has worked well in many Lean implementation projects among health care thus far (Womack and Miller 2005) and the results have been promising in cases wherein Lean has been implemented comprehensively and systematically into the hospital (Radnor, Holweg, and Waring 2012). Basically, Lean seeks to provide flowing work processes and maximal value (high-quality treatment) to the patient with the given effort. This is carried out by eliminating as many excess steps (waste) from the work process as possible. Lean practitioners have identified eight forms of waste: (i) defects (e.g. lost laboratory specimens), (ii) overproduction (e.g. too large batches of medication), (iii) transportation (e.g. moving materials, patients or information files), (iv) waiting (e.g. patients waiting for their appointment), (v) excess inventory (e.g. expired supplies), (vi) unnecessary motion (e.g. excess walking by the staff or patients), (vii) excess processing (e.g. re-writing paper-based patient forms) and (viii) the failure to develop human potential (e.g. physicians preparing patients for surgery) (Ohno 1988;Womack and Jones 2003;Chalice 2005). Lean offers a plethora of tools for the elimination of waste and work process optimization, such as the value stream map (VSM) and the 5S (Sort, Straighten, Shine, Standardize and Sustain). The performance effects of Lean increase along with higher levels of environmental complexity (leading to higher levels of waste) (Azedegan et al. 2013).
Toyota, the company mainly responsible for the development of Lean has defined five core values for Lean thinking: Teamwork, Respect, Kaizen, Genchi Genbutsu and Challenge (Liker 2003). These can be seen as fundamental cornerstones of Lean as well and are thus worth explaining to give the reader a deeper understanding of the Lean philosophy.
In order to create a mutual understanding and a sense of togetherness, Lean emphasizes Teamwork and Respect among all employees. It is important to listen to employees from different areas of work when carrying out user-centric design, especially in a patient-centred field of expertise such as health care. All employees should be encouraged to speak out and point out flaws in the work processes instead of hiding the process shortcomings (Dekker 2007). This does not just happen by ordering everyone to speak out. Lean focuses on changing the culture and atmosphere of the workplace so that these new improvement ideas will be listened to and that the foremen will respect the workers for speaking out. Even in today's work culture, health-care professionals are reluctant to inform their foremen of process flaws and present improvement ideas due to fear of malpractice and litigation concerns (Donchin 1995). Some even fear we are shifting towards a blame culture (Hignett and Lu 2009). Lean sees work processes as always being imperfect and incomplete; improving them will ultimately decrease the chance of human error. Moreover, one should not be afraid to admit and point out mistakes because they can be an invaluable source of information for the rest of the company. Togetherness, loyalty and respect among coworkers, business partners and also the community are emphasized and only an atmosphere of trust can guarantee positive results. Everyonenot only the managementis held accountable for the results and is taught to work together towards a common goal. Lean focuses on teams and also rewards them instead of individuals. This is seen as a much more effective means to gain positive results than individual punishment. Lean believes this will lead to users' improved motivation and commitment to continuous improvement ('Kaizen').
Kaizen is a Japanese word meaning continuous improvement. As no process can ever be declared perfect, there is always room for improvement. The process of Kaizen can be separated into four steps: creating stability, flowing work, standardization and incremental levelling. This is a never ending loop that starts over from the beginning once completed and the journey towards continuous improvement is never complete. Visualization is a basic fundamental of Lean and provides an effective way for all health-care professionals to learn and store information. VSM is a useful Lean visualization tool for health-care professionals for not only understanding their own work processes, but also those of co-workers. It helps avoid waste such as back and forth (and other excess) movement for both people and inventory and optimize the logistics inside the health-care facility. (Liker and Meier 2006;Reijula and Tommelein 2012) Genchi Genbutsu means going to the source of information to find the relevant facts and to make correct decisions. This is a key concept in Lean and in short it means finding the source of error and fixing it; it can be work processes or anything that interferes with efficient work. It is crucial to locate and identify the problem in person in order to correctly deal with the issue. Relying on hear-say can lead to poor error descriptions leading to wrong solutions and costly mistakes. Genchi Genbutsu helps doing things right the first time; even if this means extra effort and slightly decreased work performance from the staff in the initial stages of Lean transformation. (Liker 2003) Challenge has been defined to maintaining a long-term vision and meeting all challenges with the courage and creativity needed to realize that vision. This is prominent considering many of today's health-care design projects with sub-par execution and final results: Health-care facilities are being designed with a short-sighted vision of what the building costs are and when the facility is going to produce income. This may mean investing less initially to ensure budget margins stay positive throughout the entire project, which leads to an initial compromise and a visibly less than optimal outcome. Lean thinkers must be persistent from start to finish and willing to invest thoroughly in order to gain profits in the long run. Higher design costs and lower profits during the first few years of operating must not be seen as a burden, but rather as a long-term path towards higher rewards. Toyota has used this mindset with outstanding financial success, being the industry benchmark of automakers (Bergenwall, Chen, and White 2012).
More information on the basics of Lean philosophy can be found from following references (Liker and Meier 2006;Reijula and Tommelein 2012).

Change management
When changing from an old way of hospital design towards a user-centric and participatory facility design, the users of the facility become the centre of attention. Resistance to change among employees drastically reduces the success of any venture (Mana Gonçalves and Pereira da Silva Gonçalves 2012). Thus change management must be thoroughly understood and is one of the first challenges to conquer for the hospital management. A vast amount of the literature exists on the difficulties of change management (Carignani 2000;de Oliveira and Serra Pinheiro 2009;McDeavitt et al. 2012). In order to improve work processes, new, right patterns of work must be developed and the reasons behind the change understood. What can be accomplished, what will be the demands and costs and what will be the short-and long-term effects of the change? Change management is difficultespecially for managers (Plenert 2007). Most organizations tend towards bureaucracy, which suppresses change (Plenert 2007). People may be resistant towards change; especially so if the goals of the organization and the motivations behind the (Lean) transformation are not comprehended by the staff (Plenert 2007;Buesa 2009). People may become uncertain, insecure, anxious and even depressed due to fear of losing privacy, own personal territory and even jobs (Greenglass and Burke 2001;Buesa 2009). Employees may worry about constant disturbances and interruptions that may follow a more hectic work pace. Especially those accustomed to old work routines and patterns in the company are often against change. There may also be pessimistic people, those dissatisfied with the old work processes, but also sceptic about the change and future work processes.
There is always resistance, but with conscious, determined effort to inform and enlighten employees and increase their knowledge about the changes by opening and maintaining clear channels of communication this opposition can be minimized (Mana Gonçalves and Pereira da Silva Gonçalves 2012). Motivating the personnel by stimulating their innovation and creativity is beneficial (Plenert 2007). Directness, openness, honesty, commitment to the success of others and willingness to acknowledge problems and errors have been seen as behavioural keys to successful change management (Howard 1990). Emphasizing diversity in the workforce, recognition of individuals, ethical management practices and worker empowerment have been seen as keys to success by the business visionary Levi Strauss (Howard 1990). On the other hand, it is good to remember that resistance can also be seen as a warning signal which draws attention to aspects of change that may be poorly thought and which need alternative action models or solutions (Waddell and Sohal 1998).
Lean workshops (also called Kaizen Blitz) have been found to be an efficient way of informing staff of the upcoming change in work processes. The workshops aim at teaching the staff the basic fundamentals of Lean. Unless the employees understand the main reasons behind the change, they will not likely buy into the idea, which may ultimately lead to failure in the Lean implementation project. Lean workshops have also instilled a sense of togetherness and increased social interaction and networking among the employees in the previous Lean implementation projects (Liker and Meier 2006). Cooperation is a necessity for flowing the Lean work processes. Finally, the employees must understand the concept of continuous improvement. It is not enough to just develop new processes; they must also be continuously improved to maintain a steady incline in work efficiency.
Educating the staff about their future work processes and goals helps establish belief in the new facility design and changed work processes. This relieves much of the resistance towards change. Instilling values of togetherness and teamwork into the staff builds trust and mutual understanding between the workers, which helps coordination of teamwork when the new facility is put into operation. Also, the development of flowing work processes may improve the personnel's morale as well as their psychological well-being (Reijula et al. 2011).

User-centric and participatory health-care design
An urgent need exists for creating new, user-centric and participatory health-care facilities (Crow et al. 2002;Dinç 2009). This way of thinking has only relatively recently begun to gain momentum in health-care facility planning, but has already gathered visible support (Laine and Davidoff 1996;Duggan et al. 2006). Systematic analyses of the goals of the organization and the requirements of the work processes are used to find ways to ensure that the facilities meet the users' (employees' and patients') needs and support well-being and productivity (Rechel, Buchan, and McKee 2009). User-centric design does not necessarily have to mean participatory design; it may be based on the evidence-based research data or knowledge which a researcher collects from the users, for example, using questionnaires and checklists (Becker and Parsons 2007). The user could be quite passive without any actual participatory action in the design process (Sanders and Stappers 2008). Instead, participatory design is a process, where different stakeholders are involved in the design process in order to improve the design process itself or the outcome of the design process (Granath, Lindahl, and Rehal 1996). User involvement could be representative or direct and it could relate to the whole design process or only to a certain part of it. In participatory design, organization members are brought together to analyse problems in the organization, describe their situation, redesign the work organization and learn from each other. The focus in the facility design process is multidimensional: spatial, technical and organizational issues are discussed. The common knowledge and the objectives are questioned and developed and the participants have a genuine possibility to contribute to the goal setting and solutions (Granath, Lindahl, and Rehal 1996). Methods to facilitate participation include project teams, workshops and conferences which search for common grounds and improvement ideas (Gustavsen 1992).
Investment in user-centric and participatory health-care design has been seen to improve provider-patient communications and relationships, involve patients more thoroughly in medical decision-making, empower the patients and enable the physicians to better fulfil the patients' wants, needs and preferences (Bensing et al. 2000;Berwick 2009;Mayes 2009;Bromley 2012). Deployment of a participatory, multi-professional approach method to health-care design has also shown potential in enhancing employees' performance as well as well-being (Ulrich 2006;Rechel, Buchan, and McKee 2009). At its best, the collective design process is a multidisciplinary learning dialogue between the different users of the facility (Adler, Granath, and Lindahl 1995). All upcoming employee groups should be represented in the design phase: architects, interior designers, engineers, ergonomists, facility management, local authorization, medical planners, health-care professionals and patients should all share their knowledge in the pursuit of optimizing facility design for work processes (Clements-Croome 2004; Seim and Broberg 2010;Haron, Hamid, and Talib 2012). Especially, health-care providers' opinions, ideas and knowledge in the early stages of a hospital design provide invaluable information and expertise to hospital designers (Harun and Ibrahim 2008;Sanders and Stappers 2008;Mourshed and Zhao 2012). This way everyone has a say in the new hospital design, which may instil a feeling of belonging and togetherness, resources can be saved, fundamental flaws in the design phase can be avoided, job satisfaction can be improved, the patients' viewpoints can be better accounted for and benefits in participatory leadership can be established (Wilson and Haines 1997;Sanoff 2008).
Nevertheless, today's health-care design still tends to ignore the aspect of user-centricity (Reiling 2007). New hospitals are being built, after which the staff is asked to adjust their work processes to fit in with the new facilities. This leaves the novel facilities unsuitable for their purpose and the work environments limiting work processes instead of enhancing them. Physicians and patients have to walk excessive distances inside the hospital (for example, to fetch medical supplies or travel back and forth between treatment rooms) and staff performs administration and medication errors (Hughes and Ortiz 2005). Moreover, designers, architects, administrators and hospital staff may all have different views and opinions on how the hospital should be designed (Bromley 2012). There are also concerns that due to patients' and clinicians' lack of knowledge about the design process, their input might have limited benefit (Hignett and Lu 2009). Health-care professionals and architects may also perceive that they have insufficient knowledge of the hospital work processes as a wholespanning from the arrival of patient until the moment of his/her departure from the facilityfor planning a patient-focused hospital (Jensø and Haugen 2005). Some concerns have also been voiced that they may also possess insufficient abilities to take the patients' perspective in patient-centred hospital planning (Jensø and Haugen 2005). Increased monitoring of the health-care personnel, communication gap, coupled with lack of trust between the design team and the various user groups are also major challenges in participatory design that have had a stifling effect on health-care design (Sanders and Stappers 2008;Hignett and Lu 2009).
These issues call out for new approaches, such as Lean, to support both user-centric and participatory design approaches and to create a framework to facilitate communication within the multi-professional design team. In order to accomplish this, requirements of the work processes must be charted by using experts. In Lean they are called 'Lean Champions', whose goal is to create an understanding of work processes and goals of the organization and to function as a facilitator within the multi-disciplinary design team (Ruohomäki 2002). Also, ergonomists can be used to facilitate the involvement of clinicians and patients to engage with future designs of health-care environments (Hignett and Lu 2009). Lean, participatory and user-centric healthcare projects have all demonstrated multi-professional collaboration, participatory planning, learning, problem-solving, flexibility and teamwork (Ruohomäki 2002;Liker and Meier 2006). A significant factor for these results has been utilization of project teams, workshops (e.g. Kaizen Blitz) and conferences (Ruohomäki 2002). They have provided a great platform for socialization, togetherness and creating improvement ideas. Furthermore, Lean implementation projects have managed to create an atmosphere of trust and mutual co-dependence among the personnel. Lean has empowered employees and instilled a feeling of pride on each individual's work skills and contribution. Lean has also increased the employees' awareness of the work processes as a whole. These results seem more than promising when considering Lean as a philosophy for health-care design.
Ergonomic health-care design to promote well-being In order to prevent the costly, crucial mistakes in health-care design discussed earlier in the article information on ergonomics are already needed in the health-care facility design phase. Ergonomic approach is design driven and focuses on outcomes, e.g. performance and well-being (Dul et al. 2012). Seeking to promote well-being in a hospital: what are the main ergonomic design factors to improve the physical space? Some research results among this field have pointed out to the importance of designing safe, comfortable, functional, error-free, easily controllable and private healthcare environments (Huisman et al. 2012). Others emphasize good indoor environment qualities such as acoustics, heating, ventilation and air-conditioning systems, the visual environment and furniture (Fransson, Västfjäll, and Skoog 2007;Frontczak and Wargocki 2011;Salonen et al. 2013). In addition, several studies concern user-centred design of workstations and work tools in health care (Nevala and Ketola 2012;Nevala et al. 2013;Sormunen and Nevala 2013). According to Ulrich, the work environment should be relaxing, rejuvenating, healing and able to reduce stress and fatigue, while enhancing employees' creativity (Ulrich 1991;Ulrich et al. 2004). The goal of modern work environment design is also to create a space that enhances employees' flow of work as well as their perception of physical and psychological well-being (Reijula et al. 2011). Good hospital design can also enhance hospital ergonomics by making the facility more affective and appealing to patients and other visitors (Ayas, Eklund, and Ishihara 2008). For instance, making sure hospital users' have enough privacy, colours, child play areas and green plants in hospital waiting areas has been shown to instil a feeling of calmness among them (Ayas, Eklund, and Ishihara 2008). Hignett and Lu (2009) have identified a need for ergonomic designers to produce evidence to support safer working practices relating to spatial requirements. It was suggested that by using a set of generic room sizes for future guidance, desperately needed standardization in health-care ergonomic design might be achieved (Hignett and Lu 2009). This type of guidance has a good chance of yielding design creativity. Bromley (2012) has researched patient-centred design solutions to alter the image of a traditional hospital. Some interesting solutions include treating patient as more of a customer than a patientin short, meaning improved customer service in hospitalsand ensuring that patients and visitors rarely see technical devices and applications as well as excessive hospital equipment (Bromley 2012). In fact, the hospitals may even be transformed to look like a luxury yacht club, giving patients and visitors a 'Disney'-like wow feeling instead of the cold, sterile and mechanized life-enhancing facility that most of us think a hospital looks like (Bromley 2012).
Poorly designed work environments lead to injuries and difficulties to perform tasks . For instance, numerous manual patient handling tasks lead to high physical demands and have a statistically significant correlation with the development of low back disorders and pain (Mehta et al. 2011). Bergman et al. (2013) have developed a design support tool named 'Workstation Design Navigator' to assist workstation designers in avoiding aforementioned problems. The Workstation Design Navigator is supposed to help create more efficient and ergonomic workstations and a more efficient design process. The Workstation Design Navigator should help the designer ask right questions, gather useful information, define requirements, assist in decision-making and support evaluation of goal fulfilment . Bäckstrand et al. (2013) recommend taking a proactive, problem-preventing approach rather than a reactive, problem-solving approach in ergonomic workstation design.
From an ergonomic perspective, work processes should always include a certain amount of variation. If not, the work may become repetitive. Automatized and mechanical work processes may lead to repetitive work tasks, which may cause significant strains or injuries (Gilad 1995). The problem is further heightened if the work pace is high. For instance, increased musculoskeletal risk symptoms related to increased work pace have even been noticed in some Lean production projects (Koukolaki 2014). This becomes costly for the hospital management as it amounts to sick leave days. Doctors' and nurses' daily routines include non-value-adding activities such as walking, changing equipment and preparing a patient for surgery. These activities create variation for the physicians work routines. If Lean is implemented, a significant portion of these non-value-adding activities are eliminated and as a result the physicians may ultimately have less variation in their work routines (Reijula and Tommelein 2012). If these new, Lean work processes are not designed with ergonomic considerations in mind, a risk of strain or injury may occur. However, if health-care facilities and processes are designed ergonomically, implementation of Lean and one piece flow may in fact lead to an increase in variation among the physicians' daily tasks. Table 1 gives a short summary of the basic goals and target groups of Lean, user-centric, participative and ergonomic design approaches.
Challenges and possibilities for Lean health-care design A growing concern among health care is a need for the elimination of medical errors and rapid improvement of patient safety in hospitals (Grout 2007). Misdiagnoses and treatment errors performed by hospital physicians are alarmingly common (Aronson 2008;Font Noguera, Climent, and Poveda Andrés 2008). Making matters even worse, some of them are fatal (Dettmeyer et al. 2001;Tournel et al. 2006). In order to improve patient safety in hospitals, a new design approach is needed (Grout 2007;Grout and Toussaint 2010). The primary objectives for Lean, participatory, and user-centric approach are improvement of organizational effectiveness and employee well-being (Ruohomäki 2002). The importance of safety in accomplishing these objectives has been recognized. Lean offers a pre-emptive tool, 'Poka-yoke', designed to mistake-proof hospital processes and enhances patient safety (Liker and Meier 2006). By utilizing these tools already in the design phase, the hospital processes, facilities, furniture and space solutions can be effectively 'mistake-proofed' from the get-go. This will likely be more efficient than applying them afterwards. By decreasing the number of medical errors, significant cost reductions can be achieved alongside improved patient safety (Grout and Toussaint 2010).
A need for standardization has been identified among several aspects of hospital design (Hignett and Lu 2009). For instance, designers may use their own, random design processes parallel to the ones used by their design company . Another, wellacknowledged challenge for hospitals is being able to respond to the vastly varying demand of hospital capacity (Carey 1998). This creates costs due to hospitals having to maintain costly but rarely used standby capacity in order to be prepared to meet peak demand at all times (Gaynor and Anderson 1995;Lynk 1995). By standardizing work processes, Lean enables a relatively steady and predictable work process delivery flow, which leads to more efficient hospital space usage. Decreased hospital demand variability, in turn, decreases hospital capacity requirements, operating expenditures and therefore also hospital costs, making operation of the hospital more cost-efficient (Baker and Phibbs 2004). Although there are some who are sceptical about Involve all stakeholders in the design process in order to help ensure the designed space meets their needs and is usable Users of the space Ergonomic Optimize human well-being and overall system performance Users of the space Lean health care (Waring and Bishop 2010), it does offer an efficient and easily comprehendible methodology and tools for any institution willing to thoroughly invest in it. Hospitals are often complicated places, in which navigation is a frequent problem for patients, visitors, suppliers and the hospital staff (Huelat 2007;Mollerup 2009). In fact, health-care design presents a complex challenge due to several factors, including the large amount of uncoordinated regulation and guidance (Hignett and Lu 2009). Due to poor architecture and hospital design, patients and physicians have gotten lost in the complex hospital facilities or otherwise been confused with whom the next appointment will be with and where to proceed within the hospital (Mollerup 2009). Frankly, today's hospitals often provide either too much information at inappropriate places, confusing information, or insufficient amount of information for the user (Huelat 2007).
The problem is further emphasized on patients with sensory deficits such as impaired sight, hearing, mobility, increased anxiety and reduced mental capacities. Thus making a hospital accessible for everyone is a major aim (Lid 2013). Hospitals also have a need for an increased accessibility since the amount of appliances and insufficient space too often results in an unnerving mess of appliances, cables and tubes (Garde and Van Der Voort 2008). The resulting blinking lights and alarm beeps only make the situation worse (Garde and Van Der Voort 2008). The technical and confusing appearance of this jumble complicates the work of nurses and doctors and may even strike fear into patients and visitors (Garde and Van Der Voort 2008).
A cornerstone for Lean is making the workplace as visual as possible. This does not only mean simple, clear, visible and audible navigation paths, but also clearly and visibly illustrated work processes. Lean also attempts to create an understanding of all work processes performed within the facility (Lean term 'Jidoka') and possesses several methods and tools to accomplish this. For instance, a Lean tool named 5S attempts to organize the work space in order to enhance efficiency and effectiveness. It helps in making all tools and equipment in a workplace easily accessible and the work processes visualized so that most employees would understand what is being performed in each work station. The goal is that the employees would not have to waste time in searching for tools and equipment. As wireless devices have grown common among hospital environments, the process of creating clear work spaces has become much easier. In Figure 1, a paperless 5S Radiology workstation is shown (Knechtges, Bell, and Nagy 2013).
Lean is beneficial when focusing on long-term change philosophy for organizational development. The focus is not on the low-hanging fruit but on the continuous improvement ideal (Ruohomäki 2002). The hospital managers must thus be prepared to invest enough money and be prepared for negative budget balances for the first few years, until investment in Lean begins to pay dividends. Even though Lean requires patience and commitment to the Lean methodology, it has no 'magic tricks' or instant 'fix-it-all' solutions. Lean philosophy is based on using common sense; the main idea is to crop out everything that does not add value to the customer. Thus for designers, the design process becomes increasingly linear and goal-oriented. Table 2 attempts to illustrate a few of the previously discussed design needs in hospitals and some Lean fundamentals and tools that would seem especially fitting to answer the design needs.
Digital simulations offer several advantages compared to the traditional user-centric and participatory design methods. They enable learning complex tasks and the study of phenomena that are not easily observable in real space (Park, Lee, and Kim 2009). Digital simulations can be performed from virtually anywhere in the world. They can be carried out quickly, anonymously, and users can work in either groups or single-handedly. This would allow experts and specialists from all over the world to cooperatively design user-centric health-care facilities. For instance, a group of Lean, health care, accessibility and ergonomics specialists along with architects and designers from all over the world could simultaneously commence a virtual 'Gemba walk': this means going to see the actual hospital processes and learn the work being performed, ask questions, share ideas and figure out ways to optimize the work environment and its processes before the facility has been constructed. It would also enable future users of the space to distribute significant input on the design of the facility or even design their own work environments. Furthermore, simulations could provide a method to convey the users' needs to the architects and engineers: the users could wander virtually inside the hospital and make change suggestions by simply clicking a mouse button on a target they wish to alter. By incorporating hospital simulations into workshops (Kaizen Blitz), the users could be efficiently instructed on Lean work processes and tools. Below, a picture of a lately developed, user-centric and evidence-based hospital simulation method named VALO is presented (Figure 2).
Another aspect for creating virtual environments is creating dynamic simulation settings (Gorini et al. 2011;Villani et al. 2012). This means creating dynamic virtual models of hospital staff and patients. These models would move in real time and realistically perform the hospital processes. This would enable calculation of the duration, speed and efficiency of the hospital processes, as well as realistic evaluation of the facility design. Hospital professionals could move inside the virtual environment observing and evaluating these processes. This would hugely benefit both the hospital management and designers in making initial decisions for the upcoming health-care facility, but also in finding and eliminating waste inside the work processes, when the facility is completed and running. The Lean toolbox includes an effective but a rather unorthodox method named 'Hula-hoop' for eliminating waste and optimizing work processes. This means Lean employees have to observe their work from a circle, a hula-hoop drawn near their work spot and think of ways to improve this work process. Unfortunately, workers have experienced standing in a circle for a long time interval (between 0, 5 and 4 hours) frustrating and some have even found it demeaning. Thus simulation of the workplace offers a very alluring alternative for easy and effortless observation of work processes.

Conclusions
In order to improve crucial factors such as efficiency, safety and well-being in modern health-care buildings, new innovations from health-care designers are desperately sought after. Lean has shown great promise in enhancing work process efficiency in health-care implementation projects but has not yet been validated as a health-care facility design philosophy. Although Lean does not offer instant solutions, it may offer significant advantages in work facility, process and environment optimization compared to the most traditional methods of health-care facility design. Figure 2. In the Finnish VALO method, a realistic 3D-simulation of a hospital is projected on the wall. The user wears 3D-glasses and is able to explore the hospital environment by navigating inside the hospital using, e.g. a mouse controller.
User-centric and participatory methods have shown promise amongst health-care design and they may benefit from Lean-ideology. However, also Lean may benefit from the soft and 'humane' participatory and user-centric design methods for work processes. Lean provides a fundamentally solid ideology that may prove to be handy in helping leaders of the health-care facility cope with change management: directness, openness, honesty, commitment to the success of others and willingness to acknowledge problems and errors are key features of Lean that most likely will appeal to the staff in adopting new facilities and work processes. Lean does not seek instant results; the results of Lean implementation projects can usually be seen within a few years. Thus perseverance and thorough knowledge about Lean philosophy is required from those trying to establish a Lean hospital. A semi-committed Lean implementation project is almost always doomed to fail. However, determination and sustainability during a Lean implementation project has shown to deliver outstanding results. The question is not whether Lean will work, but rather is the Lean philosophy successfully implemented.
Ergonomic and accessibility factors must also be taken into consideration when designing new health-care facilities. With relatively cheap, minor ergonomic and accessibility investments in the design phase, major results in user well-being and also work efficiency can be achieved. For instance, the work environment design must enhance employees' flow of work as well as their perception of physical and psychological well-being. This issue is further emphasized with the aging population structure, especially in the developed countries. Reactive approach should thus be replaced with a proactive one; preventing design problems in the earliest stage possible.
Today's hospitals possess several design needs, such as improving user well-being, creating a framework for multi-professional design, standardizing hospital processes, improving patient safety, decreasing medical errors, enhancing hospital accessibility and ergonomics, making navigation easier inside hospitals and visualizing the hospital work processes. Lean toolkit includes several tools that seem promising to solve many of these issues. Thereforealike many other fields of industryalso facility design may greatly benefit from the implementation of Lean philosophy.