Lean Methodology

Lean-Oriented Layout Design of a Health Care

Facility
Flavio S. Fogliatto, PhD; Guilherme L. Tortorella, PhD; Michel J. Anzanello, PhD;
Leandro M. Tonetto, PhD

Background: In this article, we propose a method that integrates systematic layout planning techniques to lean
health care practices aided by multicriteria decision analysis that could be applied to reformulate the layout of health
care facilities. Methods: We analyze a high-variety sterilization unit of a large public hospital located in Brazil. The
unit is currently implementing lean practices, and layout changes are required to provide more efficient materials and
information flows. Results: Traditional design of health care facilities is not aligned with lean implementation and its
underlying practices and principles. We propose the integration of such approaches to enhance their benefits. To rank
and select the best layout alternative, a multicriteria decision analysis method (analytic hierarchy process) is adopted.
Downloaded from http://journals.lww.com/qmhcjournal by BhDMf5ePHKbH4TTImqenVIiuKVF7qTxsO7egTcR85zjacHn7bQz5NgBfX/SMCr66Api6VQRhA/Y= on 01/06/2019

Conclusions: There are 3 contributions here: the integration of lean principles into traditional health care facility
design practices, the use of multicriteria decision analysis to refine the determination of the best layout solution, and
the application of our propositions in a real case study.
Key words: layout planning and design, lean health care, multicriteria decision analysis, sterilization unit

H ealth care facility planning is an important part

of health infrastructure development, with sig-
nificant impact particularly on health care systems in
developing countries.1,2 Improvements in health care
facilities are imperative to ensure the operational and
financial performance of hospitals.3 Considering that
the design of hospital facilities may affect the efficiency
and effectiveness of care delivery, the use of system-
atic layout planning (SLP) techniques from the manufac-
turing industry to improve patient care and operational
performance has been advocated in the last years.4,5
Despite its relevance, research on the layout of health
care services is narrowly approached. In a systematic
literature review carried by the authors (see Tables 1
and 2), the majority of studies consulted were classi-
fied in 1 of 3 categories: (i) based on SLP and its ele-
ments, (ii) grounded on mathematical programming, or
(iii) simulation-based. Only 3 of 69 works reviewed (of
which 45, reported in Table 2, followed an identifiable
analytical approach) used multicriteria decision analysis
(MCDA) methods, and only 4 were grounded on lean
principles. The joint use of MCDA and lean, as proposed
here, was not found in any of the works reviewed.
Author Affiliations: Industrial Engineering Department, Federal
University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
(Drs Fogliatto and Anzanello); Industrial Engineering Department, Federal
University of Santa Catarina, Florianópolis, Santa Catarina, Brazil (Dr
Tortorella); and Graduate Program in Design, Universidade do Vale do Rio
dos Sinos, São Leopoldo, Rio Grande do Sul, Brazil (Dr Tonetto).
Correspondence: Flavio S. Fogliatto, PhD, Industrial Engineering
Department, Federal University of Rio Grande do Sul, Av Osvaldo Aranha,
99, 5◦ andar, Porto Alegre/RS, CEP 90035-190, Brazil
(ffogliatto@producao.ufrgs.br).
The authors declare no conflicts of interest.
Q Manage Health Care
Vol. 28, No. 1, pp. 25–32
Copyright 
C 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/QMH.0000000000000193
January–March 2019 r Volume 28 r Number 1
This article aims at integrating SLP techniques to
lean health care practices in high-variety sterile services
units. Sterilization units are critical departments in hos-
pitals and clinics since they provide materials to virtually
all other sectors, from surgery units to research labo-
ratories. We also propose the use of multicriteria deci-
sion support to evaluate alternatives derived from the
lean-oriented layout design. For that, a number of per-
formance criteria are identified with respect to which
layout alternatives are analyzed. Our propositions are
implemented in a high-variety sterile services unit of a
large public hospital located in Brazil. The unit is cur-
rently implementing lean practices, and layout changes
are required to provide more efficient materials and in-
formation flows.
METHODS
The study is carried out in a sterilization unit (SU) of
a public university hospital in Brazil. The hospital is
deemed best in the country in its category, providing
average and high complexity care through the Brazilian
Unified Health System. The SU personnel have already
been exposed to lean principles and are currently im-
plementing lean practices and techniques. However,
the department layout was not changed, compromis-
ing the adoption of some flow optimization propositions
derived from lean implementation.
The SU is responsible for the cleaning and steriliza-
tion of nondisposable instruments used during surgical
and ambulatory interventions. Proper material steriliza-
tion and its availability in time to use are important to
the hospital, decreasing the chances of infections in
patients and delays in procedures due to the unavail-
ability of sterile materials. The SU analyzed in this study
processes 18 378 parts per day; 77% of this demand
comes from the surgery unit, comprising 15 rooms.
The SU operates 3 shifts, being the second shift the
www.qmhcjournal.com 25

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26 January–March 2019 r Volume 28 r Number 1 www.qmhcjournal.com

Table 1. Information on the Systematic Literature Review on Health Care Facility Layout
Key words “Healthcare” and “Layout”; “Hospital” and “Layout”; “Clinical” and “Layout”; “Facility Layout Problem”
and “Hospital”; “Facility Layout Problem” and “Health Care”; “Facility Layout Problem” and “Clinical”;
“Systematic Layout Planning” and “Hospital”; “Systematic Layout Planning” and “Healthcare”;
“Systematic Layout Planning” and “Clinical.”
Databases consulted Scopus, ISI Web of Knowledge, Compendex, Emerald, Springer Link, Science Direct, IEEE Xplore, Wiley
Online Library, Google Scholar
Initial number of hits 3.480
Eliminated on the basis of title and abstract −3.365
Duplicated −10
Eliminated on the basis of content −49
Referenced articles added +12
Final number of hits 69
Journals with largest number of hits International Journal of Production Research (3); Automation in Construction (3); HERD: Health
Environments Research & Design Journal (3); Health Care Management Science (3)

most critical, both in terms of demand and number
of employees to be managed. There are 520 different
types of surgical kits (comprising instrument trays and
other materials) used by the specialties that operate
in the surgery rooms. In this sector, lean implementa-
tion began in September 2013, performed by a hospital
team with the aid of external consultants acting as fa-
cilitators in the development and implementation of
improvements. Our case study focused on the layout
of assembly workstations used to assemble surgical
instrument kits. To carry out the analysis, we followed
the 3 steps described next.
Step 1—Define materials and information flows
In this step, we applied a lean practice known as value
stream mapping,51 which aims at identifying improve-
ment opportunities to allow a more flexible and efficient
flow of materials and information. Initially, we carried
out an analysis of products and services offered by the
SU; the goal was to group items according to their
processing needs in coherent product/service families.
Next, the current-state map of product families was
defined, enabling the assessment of process opera-
tions with respect to waste and materials and infor-
mation flows. A future-state map was also proposed
encompassing the vision of SU coordinators and su-
pervisors regarding the future of the department. The
future-state map was grounded on 4 lean principles:
(i) maximize system’s flexibility to allow rapid adapta-
tion to changes in demand; (ii) minimize waste gener-
ation; (iii) minimize inventories, producing only when
required (just-in-time); and (iv) maximize efficiency of
materials and information flows.52 Based on the anal-
ysis of the future-state value stream, several proposi-
tions to improve value addition were outlined.
Step 2—Generate layout alternatives according
to material and information flows
This step comprises the assessment of required and
available areas within the SU to generate layout al-
ternatives, according to SLP techniques.53 Because of
existing budgetary limitations, alternatives would have
to be conservative in terms of capital expenditure to
be considered feasible. Main guidelines for developing
layout alternatives were (i) no increase in the physical
area currently available for the SU department and (ii)
no hiring of personnel, that is, the number of worksta-
tions to be arranged in new layout alternatives should
remain unchanged. Moreover, several items that influ-
ence the layout planning should not be viewed as space
planning units, imposing restrictions on layout improve-
ments. One example is the autoclaves used to sterilize
materials, which are large equipment very expensive to
be repositioned. Another example, not directly related
to equipment, is the entrance point of materials from
the surgical center: they are transported using an el-
evator, which prevents the initial processes of manual
and automatic washing to be moved from their current
position.
To generate layout alternatives, the space planning
units were first placed in a primary layout and scored
proportionally to their relevance for the implementation
of the future-state value stream (defined in Step 1);
next, existing limitations were identified in the pri-
mary layout, and different suboptimal layout alterna-
tives were created for the SU.
Step 3—Rank layout alternatives
To rank alternatives and identify the one most aligned
with lean principles, analytic hierarchy process (AHP)
was used. Analytic hierarchy process is an MCDA
method that assigns scores to alternatives according
to predefined evaluation criteria using a pairwise
comparison strategy to collect expert opinion data
and an eigenvalue-eigenvector analysis approach to
generate scores. Analytic hierarchy process has some
features deemed useful in layout studies, namely53,54 :
(i) it is a structured decision-making process that can
be documented and repeated in future studies, (ii) it is
applicable to situations that involve subjective assess-
ment of alternatives regarding criteria, (iii) it accepts

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January–March 2019 r Volume 28 r Number 1 www.qmhcjournal.com 27

Table 2. Literature on Health Care Facility Layout Classified According to Analytical Approacha
Analytical Approach
SLP (Systematic Multicriteria
Layout Planning) Mathematical Decision
Authors and Its Elements Programming Simulation Analysis Lean
√
Abraham et al6
√
Arnolds and Nickel7
√
Assem et al8
√ √
Barrett9
√
Bouchere et al10
√ √ √
Butler et al11
√ √ √
Chaklang et al12
√
Chraibi et al13
√
Chraibi et al14
√
Dela Vega et al15
√ √
Delon16
√
Elshafei17
√
Feng and Su18
√
Gibson19
√ √
Hahn and Krarup20
√
Hanne et al21
√
Helber et al22
√
Hicks et al23
√
Khadem et al24
√ √
Levary and Schmitt25
√
Liang and Chao26
√ √ √
Liggett27
√
Lin et al28
√
Lin et al29
√ √ √
Lorenz et al30
√
McDowell and Huang31
√
Meyers and Stephens32
√
Moatari-Kazerouni et al33
√
Morgareidge et al34
√ √
Motaghi et al35
√
Murtagh et al36
√
Nicholas37
√
Nickel38
√
Pazour and Meller39
√
Rossi et al40
√
Santos et al41
√
Silva et al42
(continues)

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28 January–March 2019 r Volume 28 r Number 1
Table 2. Literature on Health Care Facility Layout Classified According to Analytical Approach (Continued)
SLP (Systematic
Layout Planning)
Authors and Its Elements
√ √
Soriano-Meier43
Stummer et al44
Van Essen et al45
Vos et al46
Wang et al47
√ √
Whitehead and Eldars48
Yeh49
√
Zhang et al50
a
Tick marks indicate the types of analytical approach adopted in each study.
both quantitatively and subjectively assessed input
data, (iv) it allows measuring the quality of subjective
assessments, and (v) it is suitable for decision making
in groups. In addition, practical applications of the
method are widely documented in the literature.
Analytic hierarchy process is implemented in 3
steps55,56 : (i) organize the decision-making problem in
a hierarchical structure that reflects the relationship
between decision criteria and choice alternatives; (ii)
perform pairwise comparisons of elements positioned
in a given hierarchical level with respect to each ele-
ment in an adjacent upper level and organize the data
collected in comparison matrices; and (iii) analyze com-
parison matrices generated in (ii) by calculating maxi-
mum eigenvalues and eigenvectors and derived quality
indicators such as consistency ratios. In step (ii), pairs
of items (i, j) are evaluated in importance using a 1 to
9 scale, where 1 describes a situation in which items
i and j are equally important or preferred, and 9 de-
scribes a situation in which item i is extremely more
important or preferable than item j. Reciprocal scale
values (eg, 1/9) are used when item j is more impor-
tant or preferred than item i. More details on AHP are
given in the study by Saaty,55 among others.
Once layout alternatives were analyzed using AHP,
the one with highest associated score was presented
to the SU improvement team as best.
RESULTS
Value stream mapping was developed following the
8 guidelines proposed by Rother and Shook51 and
Duggan52 ; they are as follows: (i) define takt (ie, cycle)
time, (ii) define finished goods strategy, (iii) imple-
ment continuous flow, (iv) establish first-in, first-out
(FIFO), (v) implement pull supermarket, (vi) create
1-point scheduling, (vii) establish interval, and (viii) de-
fine pitch. Prior to the definition of materials and in-
formation flows, a 6-month implementation horizon
was targeted for the future-state map, such that team
members could reasonably work on proposed improve-
ments without losing focus of daily activities (yet not
losing the improvement momentum created so far).
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www.qmhcjournal.com
Analytical Approach
Multicriteria
Mathematical Decision
Programming Simulation Analysis Lean
√
√
√
√ √
√
Improvement opportunities elicited toward the desired
future-state are discussed by Tortorella et al,57 making
reference mainly to waste reduction, inventory levels,
and production lead times.
The future-state analysis focused on improving qual-
ity and delivery through simplification of internal pro-
cesses and standardization of procedures. The team
also assumed that in the next 6 months, the demand
for sterilized materials would remain unaltered. As for
the finished goods strategy, a pull supermarket was
initially recommended; however, due to the relatively
low current inventory and budget restrictions, a make-
to-order strategy was actually adopted. Such strategy
would also require the standardization of customers’
information flow; thus, the internal communication
form was defined as the only channel to receive cus-
tomers’ demands in the SU. Upon implementing the
proposed finished goods strategy and the FIFOs pre-
sented by Tortorella et al.57 , the new process schedul-
ing point will be the materials receiving operation. Cus-
tomers’ requirements should be scheduled at this point
and move downstream from raw materials through
FIFOs up to finished goods. The delivery procedure will
also be standardized such that all customers receive
their sterilized kits through the 5 daily delivery routes.
Once sterilized materials are delivered, used materials
should be collected along the next demand’s internal
communication form. In short, the summarized out-
comes of the future-state map analysis were (i) stan-
dardization of demand information flow from cus-
tomers; (ii) inventory sizing along the value stream
based on historical data and processing times; (iii) ca-
pacity balancing through labor reassignment; and (iv)
adoption of visual systems for materials and inventory
control.
To support the new materials and information flow
strategies, 5 layout alternatives were generated. Both
the current layout and the proposed alternatives are
shown in Figure 1. The current layout operates as fol-
lows. Materials arrive in the SU’s wet area to be manu-
ally or machine cleaned. Once cleaning is finished, the
materials are deposited on a counter in the dry area:
January–March 2019 r Volume 28 r Number 1
Figure 1. Current layout and layout alternatives for the ster-
ilization unit. FIFO indicates first-in, first-out.
those discharged from the cleaning machines are con-
ditioned in metallic trays, such that each tray contains
instruments from a single surgical kit; those manually
washed are placed in metallic trays in no specific order.
Assemblers pick kits to assemble from those available
on the counter according to their personal preferences,
or following instructions given by the shift leader usu-
ally pointing to urgent requests from the surgical cen-
ter. Since the average time to assemble each surgical
kit is not known, no production goals are established
for the assemblers. After placing trays on the assembly
table, it is not uncommon that assemblers interrupt the
assembly process (i) in search of missing instruments,
or (ii) to handle instruments not properly cleaned back
to the wet area (and wait for them to be cleaned). In-
struments to be assembled in a given kit are listed in
assembly sheets, which are used by assemblers dur-
ing the process. After assembling a number of kits, in
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www.qmhcjournal.com 29
order to empty their tables, the assemblers take their
finished work to the autoclaves, located in an adjacent
room.
A popular framework to analyze a production system
according to lean principles uses Ohno’s58 7 classes of
losses (transport, inventory, motion, waiting, overpro-
cessing, overproduction, and defects). Whenever 1 or
more losses are present in a system, there is room
for improvement.7 Analyzing the assembly process in
view of the 7 losses, 3 appear as relevant: transport,
motion, and defects. Assemblers waste operation time
with transportation, picking up materials to assemble
and, afterward, storing assembled kits in the autoclaves
sector. They also waste production time whenever they
interrupt the assembly process to pick up missing in-
struments or request additional cleaning; in view of
their current operational procedure, that could be clas-
sified as loss due to motion. Although some level of
transportation and motion is desirable to disrupt con-
tinuous tasks and avoid occupational illnesses due to
repetitive movements, we observed that assemblers
wasted more than 30% of their operational time in
those activities. Finally, losses due to defects (miss-
ing or not properly cleaned or sharpened instruments
in the assembled kit) are correlated with those other 2
losses, being also significant.
When moderating the 3 (1-hour long) brainstorming
sessions in which new layout alternatives were gen-
erated, the session leader exposed the drawbacks of
the current layout in terms of Ohno’s58 losses. The 4
criteria with respect to which alternative layouts would
be evaluated were also presented, namely, flexibility,
waste generation, inventories, and efficiency of mate-
rials and information flows. The 5 alternative layouts
presented in Figure 1 were expected to address the
losses and excel the current layout in terms of the eval-
uation criteria.
The final step in our analysis consists of using AHP
to score layout alternatives. First, the multicriteria
decision problem was organized in hierarchical form
(Figure 2). Evaluation criteria were defined according to
the 4 lean objectives proposed by Duggan.52 In our ap-
plication, N = 5. Data collection in AHP was carried out
as follows. Four experts (SU team leader, production
coordinator, assembler, and consultant) jointly filled
out 5 questionnaires in which pairs of items were
presented for evaluation. The first 4 questionnaires
presented pairs of layout alternatives, which were
compared regarding each evaluation criterion; the fifth
Figure 2. Layout decision analysis problem in hierarchical
form. SU indicates sterilization unit.
30 January–March 2019 r Volume 28 r Number 1 www.qmhcjournal.com

Table 3. Comparison Matrix—Evaluation Criteria

Waste Efficiency of Material Importance

Criteria Flexibility Generation Inventories and Information Flows Weight
Flexibility 1 3 1/2 1/5 0.14
Waste generation 1/3 1 1/2 1/4 0.09
Inventories 2 2 1 1/4.5 0.18
Efficiency of material and information 5 4 4,5 1 0.59
flows
CR 0.09
Abbreviation: CR, consistency ratio.

questionnaire presented pairs of evaluation criteria,
which were compared in importance. Comparison
matrices were created using the information from the
questionnaires; 1 such matrix with data from the fifth
questionnaire is presented in Table 3. For every matrix,
weight vectors and consistency ratios were calculated
(a simplified procedure that is given in the study by
Winston59 ). Results are shown in Tables 3 and 4.
Consistency in evaluations (expressed by consistency
ratio values <0.1) was obtained in the first round,
which may be explained by the parsimonious use of the
evaluation scale by experts. A final weight vector giving
overall scores for layout alternatives was obtained
calculating the weighted average of scores obtained
for each layout alternative regarding each criterion. Al-
ternative l2 , with an overall score of 0.304, was the one
selected.
DISCUSSION
Layout alternatives in Figure 1 took into account
changes in the assemblers’ operational procedure,
aimed at minimizing losses due to transport, motion,
and defects. In the new procedure, inspection of in-
struments and distribution of kits to assemblers were
performed by a dedicated operator (named “stork oper-
ator”) on a counter near the wet area. The assemblers
should pick their next processing order from an FIFO
station, in which jobs were sequenced for processing
such that the first one arriving would be the first to
be processed. Temporary storage areas were allocated
next to each table, aimed at the storage of finished
kits that should be transported to the autoclaves by the
stork operator. Since the stork operator was formerly
an assembler, the total number of assembly tables in
new layout alternatives was reduced to 8.
The Flexibility assessment of layouts took into con-
sideration their ability to reconfigure according to spe-
cific production needs; layouts l 2 and l 3 were deemed
best with respect to that criterion. Waste generation
considered the potential to produce waste given layout
deficiencies. Since all alternative layouts used the same
physical space, they were considered equally prefer-
able regarding that criterion. The assessment of layouts
regarding criterion Inventory considered the suitability
of areas assigned to the storage of work-in-progress
items; layouts l 1 and l 2 were deemed best with respect
to that criterion. The final and most important criterion
evaluated is the self-explanatory Efficiency of material
and information flows; layout l 2 was deemed best with
respect to that criterion.
The layout alternative with the highest overall score
was l 2 . Some of its features are noteworthy. First, as-
semblers are organized in 2 cells. Within cells, com-
munication and movement are optimized because of
proximity and easy visual contact. Temporary storage

Table 4. Alternatives’ Importance Weight Vectors and Final (Overall Score) Weight Vector
Criteria
Waste Efficiency of Material Overall
Alternatives Flexibility Generation Inventories and Information Flows Score
l1 0.14 0.20 0.28 0.21 0.212
l2 0.25 0.20 0.28 0.34 0.304a
l3 0.25 0.20 0.17 0.14 0.166
l4 0.18 0.20 0.05 0.14 0.134
l5 0.18 0.20 0.22 0.17 0.183
CR 0.04 0.00 0.09 0.04
Abbreviation: CR, consistency ratio.
a
Highest overall score among layout alternatives.

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January–March 2019 r Volume 28 r Number 1
of kits may be shared between pairs of assemblers,
minimizing space occupancy. The FIFO station is po-
sitioned in a central location, such that materials com-
ing from the inspection area are directly deposited on
the station, and assemblers may easily pick up their
next processing order from it. Transportation of assem-
bled kits from temporary storage carts to autoclaves
is facilitated by the absence of physical barriers in the
layout.
The new layout was implemented in the SU on a
Sunday, when demand for sterilized materials is min-
imal. In the month following the adoption of the new
layout, the number of extra hours contracted by the
department decreased on average by 75% because
of productivity gains derived from the new layout and
changes in the operational procedure. The final ob-
jective of setting production goals to assemblers de-
manded carrying out time-to-assembly studies on the
520 different surgical trays assembled in the depart-
ment. That was done in the following months using a
Lean Six-Sigma strategy, with results reported in the
study by Fogliatto et al.60
CONCLUSION
In this study, we propose a method that integrates
SLP techniques to lean health care practices, aided
by MCDA. Our propositions were illustrated in a case
study with the objective of reformulating the layout of
a high-variety sterile services department of a large
public hospital located in Brazil. Traditional design of
health care facilities is not aligned with lean implemen-
tation and its underlying practices and principles. We
propose the integration of such approaches to enhance
their benefits.
The research presented here carries some impor-
tant contributions to the theory of health care de-
sign. First, it proposes a method that integrates lay-
out planning techniques to support lean health care
implementation, contributing to the existing body of
knowledge on facility design practices in health care.
Second, the study incorporates a supporting tool for
the decision-making process, aimed at ranking subop-
timal alternatives and allowing selection of the best
layout.
We envision 2 further developments to the study
presented here. First, the use of poka-yoke devices
in the inspection process appears as promising. A
poka-yoke is any mechanism in a lean manufacturing
process that helps operators avoid mistakes, conse-
quently contributing to the elimination of product de-
fects by preventing, correcting, or drawing attention
to human errors as they occur.61 The 3 main defects
in the inspection process are related to missing, un-
clean, or unsharpened instruments in kits sent to as-
semblers. With the support of hospital engineers, poka-
yokes could be devised to detect those errors. Sec-
ond, the use of kanbans could improve the scheduling
promoted by the FIFO station by allowing urgent kits
to be clearly signalized to assemblers. A kanban is an
inventory-control system that allows the scheduling in
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www.qmhcjournal.com 31
just-in-time manufacturing.61 In addition to improving
the scheduling of assembly orders, the use of kanban
could also promote a simplified, visual-based control of
stored items in the final inventory.
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