Improving The Design and Permitting Process for Acute Care Facilities in California

1. Improving The Design and Permitting Process for Acute Care Facilities in California Developing a Future State Map For California Healthcare Projects June 2007 Update

2. Very Complex Projects Three or More Years From Design Start to Permit OSHPD Review Changes in Technology Limited Resources Large Batch Process Ineffective Cost Control During Design Poor Integration of Design and Construction Technology Loss of Team Members Poor Construction Phasing Challenges to Design of California Healthcare Projects

3. The Current State • Significant Construction Cost Overruns • Multiple Permit Re-submittals • Poor Drawing Quality and Coordination Between Disciplines • Loss of Team Continuity • Designers Losing Money • Owners Frustrated • OSHPD Defensive • Contractors Avoiding

4. Time for A Change • Industry Leaders Deciding To Create a Change in the Design Delivery Model • Boldt, Mazzetti, HGA, Herrero, Southland, Rutherford & Chekene, Rosendin • Application of Lean to Design Model • Tried to Generate Current State VSM • Determined need for industry wide visibility and participation

5. Healthcare Provider Meets Functional Program Requirements Meets Cost Goals Completed On-Time Built-In Quality Meets Life Cycle Requirements Satisfies Community Served OSHPD Code Compliant Submitted On Schedule Coordinated Design Complete Easily Interpreted Plans and Specifications High Quality Accurate Value to Customers

6. Meet Program Requirements Level the Design and Construction Work Flow Create More Accurate Submittal Packages Integrate Cost with Design to Manage in Real Time Create a Baseline Starting Point for the Design Process Deliver Only What “the customer” needs Keep the Design and Construction Team Integrated Throughout the Project Lifecycle Shorten the Time to Market Provide Flexibility Where Needed to Meet Program Requirements Create a Process that Will Encourage Truly Collaborative Behavior When Used Together with Other Lean Tools and Methods What Are We Trying To Achieve?

7. Progress To Date • Created Format for Five all day Workshops Sponsored By Industry and Hosted by UCB/P2SL Group • Invited the Community to Participate • Owners • OSHPD • Architects/Engineers/Designers • GC/Specialty Contractors/Vendors • Education

8. Progress To Date • Received Excellent Participation by Management from: • OSHPD (5 People) • CHW, St. Joseph's, UCSF Medical Center, Kaiser, and Sutter Health • A&E Community • CM/GC and Specialty Contractors • Between 60 and 88 participants throughout the 5 full day workshops.

9. Progress To Date • Workshop One - Focus and Results • Introduction of the Ideas and Intent of the workshops. • Hear from “Customers” what value is to them and what they are doing to improve today. • OSHPD, CHW, Sutter, St. Joseph, Kaiser • Break into four groups to map current state of each of the four Owners. • Cross functional teams pre-assigned. • Developed Initial Current State Maps • Team by Team report out of Progress and Lessons Learned

10. Progress To Date • Workshop Two - Focus and Results • Discussion and Identification of 8 Wastes • Completion of Current State Maps • Identification of Opportunities For Improvement based on Waste Identification During Current State Mapping Process • Completed Current State Maps • Identified over 200 areas of waste in existing process. • Shared results with all teams

11. Progress To Date • Workshop Three - Focus and Results • Discussion and Identification Future State Characteristics and Goals. • Identification of Near Term (future state) and Long Term (ideal state) opportunities. • Started work on both Future State and Ideal State Maps • Shared results with both teams

12. Progress To Date • Workshop Four - Focus and Results • Continued work on both Future State and Ideal State Maps and specific OFI areas. • Created a framework for continuing with this process upon completion of the five workshops. • Shared results with all teams

13. Progress To Date • Workshop Five - Focus and Results • Identified Actual Pilot Projects that will implement one or more process improvements from this workshop. • Reviewed the results of our waste priority survey. • Completed the framework for continuing with this process upon completion of the five workshops. • Shared results with all teams

14. Accomplishments • Heard from our Customers what is important to them and where they believe opportunities for improvement exist in the industry and their own existing process. OSHPD, Sutter Health, Kaiser, CHW, and St Joseph’s. • Created a current state map of the design and permitting process for four major health care organizations. • Identified specific waste in each of those process maps, where there was resistance to changing the current process and additional areas where significant opportunities for improvement exist that need to be mapped in greater detail. • Identified goals and attributes of a future state map that would reduce much of the waste in the current state processes on our way to creating an ideal state. • Began the creation of several future state maps including both near term innovation and long term ideal state opportunities. • Identified Five Actual Pilot projects where new processes will be implemented to reduce waste and increase value to the customer. • Initiated the actual mapping of four of the five pilot projects. • Defined a framework for a committee under the guidance of P2SL to continue with the development, experimentation, and implementation of this future state process through the use of pilot projects, continuing education, project specific coaching, reporting and recording, design and tracking of metrics associated with each experiment, and organizing future workshops.

15. Breakthroughs • Realizing what can happen when all of the right people are in the room at the right time focused on the right thing with the right behavior. • Understanding and accepting our own roles and barriers to the elimination of waste. • Mapping is hard work but creates high value by helping the team focus on the real value added work.

16. Images From Our Workshops

17. Images From Our Workshops

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26. Pilot Project UpdatePalo Alto Medical Foundation (PAMF) • Sutter’s Palo Alto Medical Foundation, San Carlos Center Project • Current primary focus points • Integrated OSHPD review • Elimination of waste in production of design • Target Value Design

27. OSHPD ProcessPalo Alto Medical Foundation (PAMF) • Reduce the design & permit cycle time. • Eliminate redesign • Establish processes for acceptance. • Identify the size of batches/packages and to what disciplines. • Establish clear and consistent communication procedures. • Interface protocol + Frequency • Protocol for changes. • Assigned staff stays on the job. • What’s done is done.

28. OSHPD ProcessPalo Alto Medical Foundation (PAMF)

29. Developing a Standard Plan • Three Sutter Teams • Palo Alto Medical Center • California Pacific Medical Center – CHH • Sutter Elk Grove – Prototype #1 • All Under IFOA Contract • Creating Common Approach to Design/Development/Permitting where possible • Presenting Standard Plan for OSHPD Engagement Consistent with IFOA and “Five Big Ideas” and Integrated Lean Project Delivery Process

30. Draft of Sutter Proposed OSHPD Engagement Plan • Define team members with roles, responsibilities and authority (all members: OSHPD (field and office), S-FPD, SHA, Design and Construction Group, IOR,) Includes Org Chart Template that captures this information. • Define communication plan to include: • Methods of communication (email, memos of understanding, drawings, digital models, Web X, meetings, etc.) • Channels for all communications. • Identifying Batching of data. • Expected response times for each type of communication. • Regular meeting times if and when appropriate. • Create macro level proposed design, permit, construct, occupy, value stream map indicating approval packages. • Create Schedule to inform the development of rolling Six Week Look Ahead and Weekly Work Plans. • Identify workshops to have with team to address: • Common language and lean principles. • Delivery model. • Design of the drawing and review process that makes the final review process for permit approval a validation of previous decisions and agreements. • Expectations of both sides • Identify Specific deliverables by package (what does OSHPD need to see vs. what design group thinks they want to see) • Drawing and document model, packaging, content • Define methodology to document agreements clearly • Define methodology to clearly identify common design thread throughout approval packages as it relates to code requirements • Define failure response matrix to address breakdowns in the process so that we can learn and respond to the inevitable (Plan Do Check Act loop) • Define first run study to test the complete process with a small piece. • Identify how OSHPD can get paid for their involvement, per pending legislation (SB306). • Train all members of the team (both sides)

31. Additional Challenges and Ongoing Work • Legal Boundaries for OSHPD (SB306) • Creating Ideal/Future State Map • Publishing a “Current Best Practice” Document • Presenting to Industry to Maintain Momentum (AIA, CII, ASHE, Etc) • Investigating Alternate Ideas to Aid or Speed the Process • OSHPD Review/Use of BIM/VDC models • Use of technology vs. capital limitations • Celebrating and Promoting Successes to OSHPD and Industry

32. Questions? • Suggestions? • Input? • Volunteers? • Ideas?