Fifteen years ago, PRHI presented a bold premise that has now been proven repeatedly. It posited that the same quality improvement techniques that had produced near-perfect performance in high risk, complex industries like aviation and nuclear power, could be applied successfully in health care to reduce errors, improve reliability and create efficiencies. We now know that techniques like Lean and PRHI’s own Perfecting Patient CareSM (PPC) method can reduce infections, improve patient flow, reduce laboratory errors, and enhance the management of chronic diseases.
But all these small, targeted efforts have not produced widespread and sustained quality and efficiency improvements. PRHI’s new book, Moving Beyond Repair: Perfecting Health Care demonstrates that such “spot repair” is not a substitute for enterprise-wide adoption of quality improvement methods applied to daily work in all its facets. They won’t produce the broad transformational improvements in quality and efficiency that patients seek and deserve.
Moving Beyond Repair highlights success stories of using PPC methodology to repair broken processes and to drive the larger transformation of entire organizations. Providing added momentum are new reimbursement methods, widespread adoption of information technology and increased data availability, public reporting on comparative performance, substantial incentive payments and penalties tied to achieving certain quality and safety targets. The tools and training to achieve transformation are available through PRHI.
Our aim in the book is to challenge healthcare leaders to aspire to the highest performance that system-wide adoption of Lean thinking and Perfecting Patient CareSM methodology can produce. We welcome partners who want to engage in this transformation process.
Dr. Harsha Rao, a Physician Champion and endocrinologist at the VA Pittsburgh Healthcare System, changed his clinic's approach to treating diabetes to a team model. The team model aims to improve efficiency by allowing multiple practitioners to perform all necessary tasks for each patient in a single, hour-long session. Each patient's encounter became a comprehensive care experience.
Setting up a system in which different clinicians each do different tasks associated with a patient's care was somewhat akin to setting up a production line, Dr. Rao said. He said PRHI's coaching in industry-based Perfecting Patient CareSM (PPC) principles helped with the implementation of his model. Dr. Rao said the principles were directly responsible for the fact that the team was able to increase the flow of patients during its four-hour afternoon sessions from 8 to 12 on the just the third attempt. Read entire text.
At the East Liberty Family Health Center, a federally qualified health center, Dr. Eileen Boyle believed that all medical practices would need new approaches to chronic care as private insurers and Medicare begin to pay for performance, emphasizing outcomes over the number of episodes of care a patient receives. Through the Physician Champion Program, Dr. Boyle and her team used the PPC system and it has resulted in work redesign and improvements.
"Implementing PPC has helped us design and standardize the work," said Dr. Boyle. "The successful changeover of our appointment system has generated a lot of excitement on the staff. There's no more ‘dead time' followed by ‘crush time.' Staff feels like they have more control over their environment, and more freedom to do a better job." Read entire text.
In 2003, Dr. Richard Shannon, then Director of Medicine at Allegheny General Hospital (AGH), attended PPC University and came away convinced that, by applying the principles and standardizing the work, the two intensive care units under his supervision could eliminate central line-associated bloodstream infections (CLAB) within 90 days. The results were immediate. Between 2003 and 2006, the MICU (Medical Intensive Care Unit) and CCU (Coronary Care Unit) sustained a greater than 95% reduction in CLABS and reduced deaths to zero.
But as dramatic as the progress was, it was not automatically self-sustaining. Because they were keeping real-time data, the team noticed an increase in non-standard procedures beginning in July, a month in which new residents arrived at this teaching hospital. Normal turnover meant new employees needed serious orientation. The culture of change had to be sustained.
In 2006, Dr. Jerome Granato, then CCU Medical Director, was awarded a grant by the Jewish Healthcare Foundation to expand upon his educational program for new nurses and residents. He and his team attended PPC University and set about to sustain the culture change through education. They created extensive online teaching modules and practical testing for residents and nursing new hires. The payoff for teaching central line insertion and care was huge, insisted Dr. Granato. "Here is a very common procedure; I call it the caboose of invasive procedures, because it's done by the youngest residents, with no formal training with the least degree of attending supervision. So even small degrees of training can result in big improvements, and this is certainly a case in point." Between February 2006 and February 2007, the CCU at AGH had not one single CLAB. Read entire text.
The VA Pittsburgh Healthcare System's (VA) acute care hospital on University Drive garnered national attention for all but eliminating MRSA (methicillin-resistant staphylococcus aureus) infections on the post-surgical unit, 4 West. The work began as a joint venture in 2002 between the VA, Pittsburgh Regional Health Initiative (PRHI) and the Centers for Disease Control and Prevention (CDC).
The 4 West Team Leader and PRHI staff began by improving access to equipment and materials staff needed for MRSA patients. Using PPC methodology, the improvement team helped to create a reliable supply of gowns, gloves and hand hygiene supplies, and made dozens of other improvements that freed up time for staff to devote to infection control. These improvements drove the MRSA rate on that unit from .94 infections per 1000 bed days of care in 2002 to just .27 by 2004. In addition, the entire University Drive facility began screening every patient for MRSA on admission. The hospital also tested all patients on discharge to learn whether they became colonized or infected during their stay. Due to the success of these processes in reducing MRSA infections at the University Drive VA, the same interventions were adopted at 176 VA facilities across the country. Read entire text.
TRANSITIONS OF CARE
Patient "hand-offs" can involve the day-to-day exchange of communication about patients' conditions during shift change, or more detailed information required when patients transition from one facility to another. The latter was the focus of a Physician Champion project at UPMC Montefiore Hospital, led by Dr. Adele Towers and Dr. Eric Rodriguez. The two decided to look at patients in six units on the Internal Medicine Service who were completing acute treatment in a hospital and being transferred to nursing homes for extended care. These transfers typically involved frail patients with multiple medical conditions, many of whom also have functional and cognitive impairment. Their complex medical condition had the potential to overwhelm the tenuous process of transferring information along with the patient.
Drs. Towers and Rodriguez and their committed team members attended PPC University and began to look at the communication problems through new eyes. The team took a field trip to Charles Morris Nursing and Rehabilitation Center, the nursing home run by the Jewish Association on Aging, to observe the "receiving end" of patient transfers. PPC University taught them how to untangle problems and start in one small area. It came down to a form. Read entire text.