Case Study: Lean Learning Study Trip

For a pdf: Case Study – Stanford Lean Study Trip

For more JWA Case Studies: Articles and Case Studies

Case Study: Children’s Hospital Integrated Facility Design Lean Learning Study Trip

by: Allen Hullinger


JWA led a Midwestern Children’s Hospital on a one-day lean study trip to Lucile Packard Children’s Hospital (part of Stanford Children’s Health) in Palo Alto, CA. Stanford Children’s Health (SCH) perioperative services have implemented many elements of advanced lean including level loading, a takt-based environment, and daily management. The study trip participants learned valuable lessons to apply to the design of their new buildings in their regional area and its main campus.


The Children’s Hospital was interested in applying lean principles to their new building design before moving on to the construction phase. They have been working in conjunction with JWA on implementing Integrated Facility Design (IFD), which is JWA’s process of developing new buildings and spaces using lean methodology. IFD integrates the ideas of all stakeholders into the design process of a new building. The stakeholders include patients and families, hospital administrators, physicians, staff, architects and construction management.

Before completing the building design, the hospital wanted to visit another site location where JWA has helped to implement lean practices and procedures. They wanted to learn “by seeing” how these lean tools have changed their management system. Observing another healthcare organization on-site is essential to developing the hospital’s system of lean management.

Stanford Children’s Health was chosen as the observation site because it has successfully implemented and integrated these principles into its hospital. Twelve participants traveled on the study trip including six surgeons from five specialties and the Chief Nursing Officers (CNO). JWA hosted the visit to Stanford Children’s Health’s Perioperative Unit where lean methods are used on a daily basis. These methods have moved Stanford past the introductory levels of lean into a more mature system.


One of the main objectives of visiting Stanford Children’s Health was to observe level loading in a takt-based hospital environment. Level loading helps to manage the flow of patients. This was evident as a part of daily functions at Stanford. The takt-based environment was most readily observed in the Perioperative Unit where patients move in and out of the unit at a cadence or pace. The Daily Management System (DMS) is one way that a lean system is maintained and supported, which was also demonstrated during the visit. Managers must be out on the floor daily— managing, observing and coaching to established standards and correct behaviors, not leading from the office or conference room.

The Midwestern Children’s Hospitals’ goals/objectives set forth prior to the study trip (in regards to level loading):

  • Observe and understand a level loading environment and process
  • Understand level loading’s impact on surgeon’s daily schedules
  • Prepare staff and providers for level loading

The Observations:

Evidence of a lean management system and mindset were clearly visible throughout Stanford Children’s Health. During group breakouts, the trip members observed the similarities of JWA’s IFD process, which had already been implemented and was in practice at the Midwestern Children’s Hospital. They realized the IFD process steps they employed in their own hospital were in conjunction with Stanford Children’s Health’s development of their lean management system (Packard Quality Management System).

Observing the Stanford Children's Health level loading board.

Observing the Stanford Children’s Health level loading board.

During the visit, Stanford Children’s Health presented use of lean methods in their daily practices and procedures, which showcased advancements on their lean journey. One such example was the level loading visual board for the operating rooms (OR). This board helps maintain the steady flow of patients from the operating rooms to the PACU (Post- Anesthesia Care Unit). The goal of the board is to have a patient move through the system every 20 minutes, which keeps hospital resources, staff, and beds on an even flow throughout the day. This board is a portion of the takt-based environment maintained in the OR. Physicians and schedulers must work together and in conjunction with other departments in order to update the board. This visual board helps maintain open communication across all departments that interact in the OR.

During one learning exercise, the study trip participants were asked to apply the lean principle of “see and do” or hands-on learning to update the level loading board. Each of the six clinicians took one patient from the upcoming surgery list, and with assistance from Stanford Children’s Health schedulers and physicians, applied their learning to level load the following two days that set the actual master surgery schedule.

Participant Feedback:

Lean requires hands-on experimentation in order to deepen the understanding and refine process thinking. In learning from Stanford Children’s Health, the team received valuable insight to develop processes and methods at their own organization. They also gained the skills needed to engage staff and physicians in the development of these tools.

Based on reflections, feedback, and formal surveys, it is evident that participants found the study trip to be a valuable learning experience. One surgeon commented: “Eyes on site are better than 10,000 words,” while another expressed that it was powerful to see “boards in action and evolution” throughout Stanford Children’s Health organization.

Next Steps:

The study trip participants will need to continually engage and commit to taking the next steps to lead their organization in the development and engagement of new and improved processes.

The team compiled their “Likes, Please Considers, and Next Steps” to help guide them as they take the next steps in the IFD process and in turn advance to the next phase of their lean journey. [See Table 1 below]

The major steps in their next phase include:

  • Implement Daily Management System with the hospital system
  • Recruit and train lean leaders at all levels of management
  • Hold an Rapid Process Improvement (RPI) event in order to create a level loading tool with the purpose of applying it within the hospital system
  • Performance improvement interns and program
  • Staff allocated to improvement
  • Management commitment
  • Leadership driven
  • Staff involvement
  • Morning rounds/huddles
  • Staff drive improvements
  • Consistency of attempts to improve


  • Including surgeons in rounding and events
  • Location of level loading board to more public main OR area
  • Include turnover time or rooms


  • Daily Management System (DMS) implemented within the hospital system
  • Recruit and train lean leaders at all levels of management
  • Lean education for all staff
  • Hold a Rapid Process Improvement (RPI) event to create a level loading system and tool to be used in the new hospital building
  • Test level loading tool


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