Background One of our children’s hospices is almost 30 years old, and modernisation is required if we are to continue providing excellent paediatric palliative care in the future. An initial scoping study was commissioned, informed by technical and structural building information, combined with an understanding of how care is delivered and experienced within the facility.

Aims To use Lean Healthcare (D’Andreamatteo, Ianni, Lega, et al. Health Policy. 2015;119(9): 1197–1209) tools, based on the Lean management philosophy developed by Toyota, to ascertain structural challenges in an ageing children’s hospice, and to identify improvements to the building that would enhance the care experience.

Methods Value Stream Mapping (VSM) (Gellad, Day. Am J Gastroenterol. 2016;111(4) 447–448), a Lean tool for defining steps in complex interactions, was used to identify physical areas of the hospice that posed challenges for care delivery, and reduced the value of services.

The goal of VSM is to create a shared understanding, and the multi-disciplinary care team and supported children and families were involved by using participative data collection tools:

• Emotional touchpoints (Healthcare Improvement Scotland. Emotional touchpoints. [internet] 2020) identified the feelings areas of the building elicited in children and families.

• Cross Sectional Observation Studies (Setia. Indian J Dermatol. 2016; 61(3) 261–4) collected data at points of time by viewing clinical care delivery and family interactions in the hospice.

• Video reflexive ethnography (Collier. Lights, camera, reflection: using video to identify and understand every day brilliant palliative care, as a starting point for improvement. Unpublished paper presented at The Scottish Partnership for Palliative Care Conference; 2023) captured the complexities of the environment directly from the perspective of supported children.

Results Different emotional responses, both positive and negative, from 30 families, supported a series of observational studies, identifying nine areas of the hospice requiring significant structural and design improvements. Videos, taken directly from the views of supported children, accompanied the findings, highlighting the changes necessary from their perspectives.

Conclusion Visual representations were combined creating a detailed value stream map of the hospice. The recommended improvements formed the basis of a business case which will be considered as part of future decision making on the size and scope of hospice refurbishment necessary.