To add to the complexity of this project, the hospital was not a replacement facility but rather a new hospital meant to fit a niche in the Ministry Healthcare System and it was the Ministry's first all-digital facility.

As a result, the entire leadership team and employed staff needed to

Recruiting for the leadership team began almost two years prior to the opening of the hospital. One of its first tasks was to develop a collective approach to bringing this project to fruition. The initial core group of leaders had experience in various settings using the principles of Lean enterprise.

The intellectual foundation of Lean enterprise was established by Dr. W. Edwards Deming and its development is credited to Taiichi Ohno and the Toyota Motor Corporation. Toyota embraced Deming's view that business management required a long-term philosophy.

The key to Toyota's success is their culture with its focus on the absolute elimination of waste and a devotion to continuous process improvement. All Toyota employees have this culture instilled in them, becoming a natural part of the way they work.

Another key element of Lean enterprise is relying on frontline staff to identify opportunities for process improvement and carry out improvement projects. The result is a learning organization focused on continuous improvement to produce long-lasting success.

For our project, we needed to deliver on time, a fully staffed and functioning new hospital that operated using an all-digital environment. To accomplish all of this and create an environment of sustainable, continuous quality improvement, we felt it was important to create a corporate culture that made the use of these management tools a natural part of our operations.

Culture

We knew early on that achieving all of our goals would require a positive, high-performing corporate culture. We also understood that an organization has limited ability to create a culture.

To create a positive culture we decided that the best approach was to define a key set of values and then live them. We started with the core values defined for the entire Ministry Health Care System: service, vision, justice and presence.

We added to this the core values of Lean enterprise that includes a philosophy of long-term thinking, process efficiency, respecting and challenging people, and an environment of continuous learning and improvement. Finally, we tied this all together with the core values of having fun and working together while striving to meet the deadlines of opening a new hospital.

The process of building our desired culture began with recruiting. Selection of senior leaders involved a process that included extensive evaluation by an industrial psychology firm to assess competencies, potential, and interpersonal fit within the senior leadership team.

Other recruiting efforts involved careful development of job descriptions and interview techniques that included evaluation of cultural fit within the organization.

Finally, a personality inventory tool that assessed individual approaches to thinking, communicating, problem-solving and coping with stress was used by the entire leadership team. This tool produced an easy-to-use one-page color graphic representation of each person's The swat team has proven so successful that they continue to meet more than two years following our opening. individual style, which formed the basis of an extensive training program for its interpretation.

The personality inventory and its accompanying training program proved to be one of the most useful tools for helping people establish and maintain interpersonal relationships.

Instilling the values that we hoped would lead to our desired corporate culture began with the new employee orientation process. The entire senior leadership team met with new employees at the beginning of their orientation to discuss our core values and goals. Feedback from employees on this approach was very positive.

Within our culture-building efforts, we have sought to incorporate the generational differences among our employees. The lure of a new hospital and an all-digital environment combined to attract a staff that is significantly younger than that of the typical hospital. Numerous team-building efforts occurred to help form relations between the staff and help cement our new culture.

Physicians were actively included in building the culture. Hiring physicians to provide dedicated medical director services for the four divisions of the medical staff turned out to be a critical element in our success.

The senior leadership team incorporated the medical directors from the beginning, including them in all aspects of the new hospital's development and operations. The intimate, daily involvement of the medical directors in every aspect of the project created a powerful message from the beginning in our culture creation efforts.

In addition, numerous other physicians participated in various aspects of this project relevant to their specialty interests. As we identified opportunities for process improvement, affected physicians were included in the process improvement teams whenever possible. For our staff, including physicians on these teams is an expectation.

In the end, the development of the Saint Clare's culture exceeded all of our expectations and was our greatest success. As the culture developed, it dovetailed with our use of the principles of Lean. Our use of these principles began with our approach to project management.

Project management

Because Saint Clare's Hospital was Ministry's first all-digital hospital we did not have a "blueprint" for this project and we knew early on that we would need a systematic approach to breaking the project into manageable pieces.

A core principle of Lean management is the use of teachers to impart knowledge to staff to expand the organization's capabilities for process improvement. For this project, we used a team of professional project managers, assigning them to work with various multi-disciplinary teams involved with the project's development. Their primary function was to facilitate team processes, ensure timelines were met and teach the staff project management techniques to help embed these tools in our culture.

At all stages of this project, we worked to include the perspective of patients, physicians and employees into our design and implementation plans. We also did extensive benchmarking, contacting numerous other entities with hospitals recently opened or under construction.

We collaborated with Joint Commission Resources to help us identify best practices from hospitals across the country in the development of our clinical policies and procedures. One benefit of this benchmarking approach is that it energized our staff as they discovered that they could set process standards at best practice levels across the organization.

Tools

The key tool of our project management approach was process mapping. Opening the new hospital involved the creation of nearly 8,500 pages of process maps. Process mapping remains our first line-approach to developing new services and improving processes.

Under the tutelage of project managers, multidisciplinary teams including physicians, managers, administrators and most importantly, frontline staff were brought together to design processes. The focus of our process mapping was to avoid waste or "muda" in Lean terminology.

More specifically, we sought to keep patient and staff movements simple and direct, avoid potential delays and ban re-work in our processes. As our managers and staff have become more adept with the tools, our reliance on project managers has decreased and allowed us to deploy them to other hospitals in our system.

In the months prior to opening after we gained access to the building, we tested our process maps by running simulations. Simulations included staff and physicians from appropriate areas within the hospital as well as "independent eyes" to bring external perspective to test our process maps as rigorously as possible.

Opening the new hospital involved creating and running nearly 200 patient simulations. The use of simulations remains a commonly used tool as we develop new services.

In addition, our all-digital environment facilitated our application of the principles of Lean to our hospital. The Marshfield Clinic, a large, regional multispecialty clinic provides the great majority of our medical staff. Our organizations share an electronic medical record that has been in use by the Marshfield Clinic for more than 20 years. Physicians are able to access office and hospital records instantaneously and without regard to location.

The system allowed us to avoid ordering unnecessary or duplicate tests, especially in the emergency room. Our computerized physician order entry system (CPOE) has allowed us to eliminate entire classes of medication errors and greatly increase the speed with which we deliver care. The CPOE system is also one of our greatest challenges as it creates new opportunities for error.

Although the implementation of the all-digital environment has been a challenge, its benefits to patient care greatly outweigh the difficulties.

Process improvement

An important element of Lean is not tolerating defective processes. We used a number of approaches to dealing with problems following the opening the hospital. For problems that needed to be fixed immediately we had daily "SWAT Team" meetings (in the early days, sometimes twice per day).

These meetings involved physicians, frontline staff and managers, IT support and administration, and were intended to address issues that directly impacted patients, physicians and staff. The focus was on significant quality or patient safety risks.

Many of these initial problems involved the flow of information and were due to lack of familiarity with IT systems and internal software glitches. Analysis and resolution of problems identified by this group typically required no more than a few days.

For patient care processes that did not work as well in practice as we had hoped in our initial design phase but were too complex to fix on an immediate basis, we formed a team called the Inpatient Operations Group. This group consisted of physicians, frontline managers, IT support and administration.

Upon identification of a problem, this group would create subteams that brought in frontline staff to analyze the situation and seek solutions. The primary tools we used for this analysis were root cause analysis and failure mode and effects analysis. To assist in the identification of problems we have a heavily used incident reporting system.

We routinely question processes and do not assume that just because a process is working that an opportunity for improvement does not exist. Revisiting complex processes and thoroughly re-mapping them has proved very beneficial to improving patient care over time.

Benefits

Since our opening two years ago, we have steadily expanded services and are completing our first addition of new inpatient beds. We enjoy high patient and employee satisfaction scores as well as excellent quality indicator metrics. The key to our success has been to create a culture grounded in the concepts of the TPS while at the same time making it a natural part of the way we work rather than a management strategy or fad.

Our organizational culture created a staff that has a sense of ownership in everything we do.This culture has also created a high degree of physician engagement in our project.

All significant projects and problems are tackled with project management tools and process mapping. They are handled in rapid cycles, which have become an expectation of our staff. People feel comfortable reporting issues and identifying the need for process improvement. The challenge we face is maintaining this positive culture but we know that our long-term success, like Toyota, depends on maintaining it.

RELATED ARTICLE: Saint Clare's Clinical Swat Team in Action

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Sometimes the smallest errors can create the biggest problems. One of the first issues that the clinical swat team had to address was a problem raised by our anesthesiologists.

In the first few days following our opening, a patient presented for emergency surgery from our emergency department whose name did not appear in the operating room/anesthesia patient information system. This was despite the fact that the patient had been registered in the emergency department.

This problem forced the OR staff to create a "dummy" account to allow the now-delayed case to proceed and required staff from the medical records department to merge the "dummy" record into the proper patient account as soon as possible after the case. Over the next few days, similar problems occurred with additional patients presenting for surgery.

It was not initially clear what the source of the problem was and the swat team took up the issue. Discussion did not reveal an obvious answer. An IT staff member investigated the entry of the patient's demographic information and traced the problem to a misspelled name.

Once we learned this, a meeting was arranged with registration staff to emphasize the importance of correct data entry and create a secondary check on the name entry. Although this resolved the problem, it was not long before we learned of other registration troubles. Problems were arising with information flow to lab ordering, pharmacy and patient financial services for example.

It became clear that we had missed something in the development of our registration processes. Rather than have the clinical swat team try to resolve this issue, we passed the matter on to the inpatient operations group, which had responsibility for addressing complex problems.

This group examined the process maps for registration and revised them to include more staff training and additional checks built into the system to ensure accuracy of data entry. This ultimately produced a highly accurate registration process and resolved our problems related to this process.

We learned a key lesson with this problem. In an all-digital environment, the simple process of registration becomes critical and there is little opportunity to clean up mistakes after the fact. A side benefit was that our registration staff came to understand that they played a critical role in the successful care of patients.

Our tracking log includes hundreds of other issues, big and small, addressed by the clinical swat team in the early days following the hospital's opening.

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RELATED ARTICLE: Ministry Health Care's Values

Fundamental beliefs that guide behavior of individuals

* We provide holistic SERVICE that meets people's needs while considering the good of society. We involve people in decisions that are important to them.

* Our Christian beliefs shape our VISION of social responsibility. We enable risk-taking and reward creativity that improves people's quality of life.

* Wherever we are, our PRESENCE is marked by compassion, integrity, collaboration and accountability. We set future directions that assure the dignity and development of people above all else.

* We stand with the poor. JUSTICE calls us to confront conditions of oppression and to help change structures that violate people's dignity.

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IN THIS ARTICLE ...

Efforts to build an all-digital hospital include much more than fancy electronics. A new hospital in Wisconsin also built its culture, adopted a new project management process, and developed new tools to help manage all aspects of the hospital.

Larry T.Heland, MD, MMM, is chief medical officer of Saint Clare's Hospitial in Weston, Wisconsin. He can be reached at larry. hegland@sainclarshopital.org

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Mary Kruger, RN, MS, president and chief operating officer at Saint Clare's Hopital in Weston, Wisconsin. She can be reached at mary.krueger@saintclarespital.org

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Related Column:

By Larry T. Hegland, MD, MMM, and Mary Kruger, RN, MS