Pittsburgh Regional Healthcare Initiative

In Pittsburgh, an entire region is working together with relentless focus on solving problems at the point of patient care. Doing so will improve the quality of care for every patient, improve working conditions for healthcare workers, and reduce waste and opportunities for error endemic in today’s system.

Situation

In Southwestern Pennsylvania, healthcare is the largest sector of the economy, employing one in eight workers and conducting more than $7.2 billion in business. Yet in 1998, as civic leaders began formulating an ambitious regional renewal, the industry was under growing pressure with bankruptcies, operating losses, consolidations, and difficulty retaining qualified workers. Purchasers bemoaned the high cost of care; the region's quality indicators did not set national records.

To address these challenges, the Pittsburgh Regional Healthcare Initiative (PRHI) was formed under the leadership of then Alcoa Chairman Paul O'Neill and the Jewish Healthcare Foundation of Pittsburgh.

Solution

PRHI's approach to redesigning healthcare requires cooperation among previously competing interests. In addition to hundreds of clinicians, PRHI's members include 40 hospitals, four major insurers, over 30 majorand small-business healthcare purchasers, dozens of corporate and civic leaders, and Pennsylvania's attorney general. This divergent group united in endorsing one guiding principle: healthcare delivery must focus on providing perfect care to every patient.

PRHI partners have come to realize that the challenges facing healthcare are symptoms of the same root problem: not faulty people, but faulty, error-prone systems that do not focus on patients at the point of care. Every patient intervention must become an opportunity to learn, share what they learn across the entire region, and apply the discoveries.

Goals: PRHI partners signed formal commitments to collaborate on ways to accelerate progress toward these goals:

• Zero medication errors
• Zero hospital-acquired infections
• The best patient outcomes in the following areas:
  • Coronary artery bypass graft surgery
  • Hip and knee replacement surgery
  • Maternal and infant outcomes
  • Diabetes
  • Depression

In pursuit of these goals, PRHI supports three sequential levels of shared learning and improvement:

Working Groups/Registries

PRHI partners have constructed formal mechanisms for bringing the scientific method into the care of every patient in the region. Examples include:

• Coronary artery bypass graft surgery:
  • Regional Cardiac Registry, with all partner cardiac surgery centers collecting and sharing data on numerous processes of care, to help determine which processes help patients return to health sooner and more completely. The registry is supported by the Centers for Medicare and Medicaid Services.
  • Quarterly Cardiac Forums, where representatives from the partner cardiac surgery centers review and discuss the most recent outcomes data.
• Perfect treatment for diabetes and depression: this group of clinicians is working with insurers and quality improvement organizations on a model that will provide all of the area's primary care physicians with up-to-the-minute information on the status of each patient's lab values and the last time various tests were performed.

Real-time reporting and root-cause problem-solving systems

When errors are buried, the opportunity to learn from them is lost. The goal for this area of the initiative is for every medication error to be reported and investigated to root cause within 24 hours, as close as possible to where the work is done, and shared immediately with everyone in the organization.

Real-time reporting provides a searing contrast with way error reporting and investigation are usually done in healthcare, placing enormous demands on leaders and forcing institutions to become adept at solving problems rapidly. The real-time reporting system is inspired by the one in use at Alcoa, where the lost workday rate is now 36 times better than the average American hospital.

To make real-time error reporting work, PRHI field managers visit hospitals across the region helping them install and put to fullest use the MedMARx medication error reporting system. Each hospital also has access to the Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS) for tracking hospitalacquired infections.

Reporting, learning and improvement take place when employees feel professionally safe and when top hospital management creates a blamefree, non-punitive environment along with the expectation that every error will be reported. Introducing MedMARx into a professionally safe environment as a tool for reporting and solving every error within 24 hours offers hospitals a means of accelerating progress toward zero medication errors through rapid, decentralized problem-solving.

Perfecting the Patient Care System

For organizations that have made a full commitment to safety and decentralized problem solving, PRHI has introduced a way to design organizations t a) allow everyone to learn from errors and problems, and b) improve healthcare delivery processes quickly, frequently, and at low cost. PRHI adapted the Perfecting Patient Care (PPC) System for use in healthcare from the principles of the Toyota Production System. PRHI currently includes:

• Learning Lines. In several hospital units in the region, PPC Learning Lines, unique problem solving laboratories, design solutions to problems that interfere with meeting patient needs. Working with a Team Leader, those on the Learning Lines apply scientific discipline to solving problems one by one, immediately, in the course of work.
• Shared Learning. Participants may enroll in classes to learn more about the application of Perfecting Patient Care principles in the course of work.
  • The PPC Introductory Session provides a chance to learn the basics of the Perfecting Patient Care System (PPC). This interactive learning session, based on a Harvard hospital case study, is an oppor tunity to get better acquainted with the PPC process and how it works.
  • The PPC University is an intensive, four-day course where participants "learn by doing." It is based on the original design from Harvard Business School and Alcoa, Inc. The four-day session varies in format with case studies, role playing, videos, miniexercises, a book discussion, and presentations-augmented with observations on a hospital learning line.
  • The PPC University has been recognized by the Accreditation Council for Continuing Medical Education (ACCME) which grants 0.27 continuing education units (CEUs) to those who complete it.
  • National Clinical Improvement Network (NCIN). Across the country, organizations and individuals are building knowledge about how to improve healthcare delivery systems in a complex environment. PRHI founded NCIN as a way to connect people focusing on point of care improvements in an authentic way through site visits. Eventually, NCIN hopes to develop a quality partnership with a Federal Working Group so some Federal policymakers might have a place to come and learn about problem solving at the point of care. NCIN participants include:
    • Rochester Health Commission, NY
    • Sutter Health System, Sacramento, CA
    • Luther Midlefort, Mayo Health System, Eau Claire, WI
    • Atlantic Health System, NJ
    • 5 Intermountain Healthcare, Salt Lake City, UT
    • Institute For Clinical Systems Improvement, Bloomington, MN
    • The Reinertzen Group, Alta, WY
    • Jcaho, Oakbrook Terrace, IL
    • Northern New England Cardiovascular Study Group, Manchester, NH

Better Health & Lower Costs

In Pittsburgh an entire region is working together with relentless focus on solving problems at the point of patient care. Doing so will improve the quality of care for every patient, improve working conditions for healthcare workers, and reduce waste and opportunities for error endemic in today's system.

Summary of progress to date:

• Regional baselines have been established in all five clinical conditions: cardiac, orthopedics, obstetrics, diabetes, and depression.
• Regional baselines have been established in two classes of infection: methicyllin-resistant staphylococcus aureus and central-line associat ed bloodstream infections in intensive care units.
• Over 7,000 medication errors were reported and shared last year— fully 18% of the national MedMARx total.
• A state report published in 2000 shows the Pittsburgh region to have the lowest post-CABG mortality in the state—a point from which PRHI hopes to accelerate improvement.

National Funders:

• Centers for Medicare and Medicaid Services (CMS)
• Centers for Disease Control and Prevention (CDC)
• Agency for Healthcare Research and Quality (AHRQ)
• Robert Wood Johnson Foundation (RWJF)

Local Community Funders:

• Aetna U.S. Healthcare Foundation
• Alcoa Foundation
• Allegheny Technologies, Inc.
• AT&T
• Claude Worthington Benedum Foundation
• Dietrich Industries, Inc.
• Dollar Bank Foundation
• Equitable Resources
• Federated Investors, Inc.
• FedEx Ground Package System, Inc.
• Giant Eagle, Inc.
• The Hillman Foundation, Inc.
• Kirkpatrick & Lockhart, LLP
• McKesson HBOC Automated Healthcare
• Mellon Financial Corporation
• Richard King Mellon Foundation
• Mine Safety Appliances Company
• The Pittsburgh Foundation
• PPG Foundation
• PNC Financial Services Group
• SMC Business Councils
• USS Foundation, Inc.