Executive Interview: Nothing Short of Perfect

Borrowing from the automaker Toyota, Karen Feinstein urges healthcare providers not to ignore mistakes.

What’s the difference between caring for a patient and building a car? At first glance, lots. But on second thought, maybe not so much. For example, Toyota institutes certain processes to ensure every car coming off the line is of the highest quality. It means respecting and trusting frontline workers. Assembly line workers and managers must have vigilance to be constantly on the lookout for trouble before it undermines their hard work.

Sadly, experts say many automakers do a better job building cars than hospitals do taking care of people. Sometimes, even the best-intentioned hospitals and hospital workers make mistakes that result in illnesses and even deaths, not to mention high costs. But does it have to be that way? Karen Feinstein doesn’t think so.

Feinstein is co-founder and current chair of the Pittsburgh Regional Healthcare Initiative (PRHI) and president of the Jewish Healthcare Foundation (JHF). (PRHI is a supporting organization of the Jewish Healthcare Foundation.) With a Ph.D. in social welfare policy, particularly labor force economics, Weinstein took a circuitous route to healthcare.

“I perceive myself as a social change agent,” she says. In fact, she worked in the War on Poverty and United Way prior to getting into healthcare. Given her experience in organizing groups of people around common causes, Feinstein appeared to be the ideal candidate to head up the newly created Jewish Healthcare Foundation in 1990.

JHF was created when the board of Pittsburgh’s Montefiore Hospital separated the hospital (which today is part of the University of Pittsburgh Medical Center) from the Jewish Healthcare Foundation. Its mission is to support programs that improve the quality of healthcare for people in the Pittsburgh area, including support for programs in breast cancer research, education and detection, and support for biomedical and biotechnology research.

Feinstein got her first hard look at how hospitals operate while helping care for two of her relatives. For a person who had taught management at Carnegie Mellon in Pittsburgh, the experience was an eye-opener.

“I couldn’t believe it,” she says. “The work design was counter to everything we taught.” She wondered if this particular hospital was an aberration. But friends told her it wasn’t. “Deming hadn’t yet gotten to healthcare,” she says, referring to quality management guru W. Edwards Deming.

But Feinstein refused to accept the status quo. Instead, she sought advice and counsel from people outside the healthcare industry. She had to look no further than the aluminum producer Alcoa, a local company that was touted as one of the safest and highest performing corporations in the world. Its CEO was a former Office of Management and Budget (OMB) official named Paul O’Neill (who later went on to gain notoriety as U.S. Secretary of the Treasury from January 2001 to December 2002.) While at OMB, O’Neill had worked with the Veterans Affairs health system and had firsthand knowledge of healthcare.

O’Neill was a huge fan of the Toyota production system, and he worked diligently to instill it in Alcoa’s employees. So Feinstein popped the big question. “I asked him if he would help me transform healthcare,” she says. To jump-start the process, O’Neill gave the JHF 12 spots at Alcoa University so that local hospital administrators could attend a class on healthcare quality.

“We were very impressed not only by the Toyota principles, but by Paul’s conditions for doing work with us,” recalls Feinstein. O’Neill had three strong beliefs, to which he insisted JHF subscribe if the two were to collaborate:

Healthcare is local; those who truly want to change it should not wait for national policies
Most problems are solved by the people who are engaged in the work, not by ivory tower managers
Healthcare providers should de-emphasize benchmarking with other institutions (which tends to rally people around mid-level performance levels) and, instead, focus on achieving excellence.

“It’s that working toward perfection that motivates us to reach a point of doing excellent work and to stay excellent,” says Feinstein. “That was the beginning, and we were off.”

By 1997, many citizens and healthcare professionals in Pittsburgh agreed that healthcare was a huge problem for the region. Providers were facing bankruptcies, operating losses, consolidation and difficulty retaining qualified workers. Costs were high, but quality of care was not. If the region were to develop a regional renewal plan, it would have to address these issues.

It was with these concerns in mind that Feinstein and O’Neill became founding co-chairs of the Pittsburgh Regional Healthcare Initiative. Comprised of hundreds of clinicians, more than 40 hospitals, four major insurers and dozens of large- and small-business healthcare purchasers, PRHI was (and remains) dedicated to achieving the world’s best patient outcomes by creating a superior health system, by identifying and solving problems at the point of care.

The organization articulated a handful of ambitious goals:

  • Zero medication errors
  • Zero hospital-acquired infections
  • The world’s best patient outcomes in
  • Coronary artery bypass graft surgery
  • Hip and knee replacement surgeries
  • Maternal and infant outcomes
  • Diabetes
  • Depression.

To help gauge progress, PRHI decided to track the processes of care that most likely propel patients to complete recovery, as well as the ability of Pittsburgh-area healthcare providers to learn from problems, thereby improving healthcare delivery processes quickly, frequently and at low cost.

The Journal of Healthcare Contracting recently spoke with Feinstein about her efforts to perfect patient care in Pittsburgh.

The Journal of Healthcare Contracting: Describe your initial thoughts about improving the quality of healthcare.

Dr. Karen Feinstein: We started out by looking at the high cost of healthcare. It occurred to me that maybe we had been looking at the problem wrongly. My background was in labor economics. I said, “Healthcare isn’t so precious.” One of the best ways to drive down costs is through quality. The issue was, “Does the value proposition work in healthcare?” It seemed that running an organization safely and efficiently would probably be every bit as valuable in healthcare as any other industry.

JHC: Regarding the founding of PRHI, what was your model?

Feinstein: Having had experience with the War on Poverty and United Way, I always had an interest in how local communities solved problems. That’s how PRHI became a collaborative effort. And we borrowed a page from Toyota, which opens their plants to any visitors. Anyone can go to a Toyota plant to see the methodology. They feel that doing things right is something that should be shared. Everyone is working together to improve processes.

JHC: What are the difficulties in improving the quality of healthcare?

Feinstein: The culture of healthcare makes any kind of change very difficult. There’s a feeling that “It’s always been done this way,” even in the face of evidence [showing otherwise]. The culture in many institutions is secretive. People don’t acknowledge problems, so they can’t share solutions. Nor are healthcare [sites] structured for people to meet and talk about problems. There aren’t regular meeting times for people to get together and share information about solving problems in the course of their work or making improvements in patient outcomes. You get islands of excellence, but the excellence doesn’t spread throughout the institution.

Toyota principles suggest that frontline workers in the course of their work should aim in every way for zero defects. Everything that one does during the day should add value to the overall enterprise. Work is streamlined for the best possible outcomes. Whenever a problem is identified that interferes with excellent outcomes, the people doing the work immediately look for its cause and then work to eliminate it. I would add that there is immediate acknowledgement of pathways of errors.

But they are not just responding to problems. People trained in the Toyota production system are always alert for opportunities to streamline the work and make it more efficient.

JHC: To what extent has PRHI been able to help instill this attitude in healthcare workers?

Feinstein: We’ve been most successful in the area of hospital-acquired infections. We would say that almost all such infections are preventable. We’ve been lucky in that we have received a lot of support among physician leaders, who have reduced certain infections virtually to zero. This has been particularly true in intensive care units and critical care medicine. We have reduced central line infections by almost 60 percent. And we have worked with a VA medical-surgical unit, which brought [methicillin-resistant Staphylococcus aureus] virtually to zero.

We’ve been so impressed by basic Toyota principles that we have created our own university: Perfecting Patient Care. We have a five-day course that has been attended by more than 3,000 people.

JHC: University aside, how do you influence people on the units on a day-by-day basis?

Feinstein: We have people who act as coaches and mentors, who are helping in getting a unit started and supporting the process of continuing improvement. But somewhere along the line, a passion for work-line improvement has to become part of the sensibility of the workers in the unit. We can help get things started, but if there isn’t enthusiasm among the team providing care on the frontline, you can’t do much.

JHC: Why does PRHI focus on a few specific goals rather than take a broader-based approach?

Feinstein: If we were adopting a pure Toyota approach, we would be teaching people to solve problems as they come up, without prioritizing them, with no particular focus other than the overall mission of the organization. (Toyota’s mission is to produce a customized automobile for every customer when he needs it.)

But for healthcare, we felt we needed to have some focus. So we chose five areas:

  • Hospital-acquired infections
  • Continuing care for chronic diseases
  • Diabetes
  • Depression
  • Child development, focusing on the early diagnosis and treatment of developmental disorders.

We have directors for each of the five areas, but we’ve found they overlap tremendously.

JHC: What is the economic case for zero defects?

Feinstein: It’s tedious work. Hospitals aren’t set up to look at the cost of errors. But we have been able to demonstrate that in the case of hospital-acquired infections, not only does the patient suffer, but the hospital and insurer suffer, too. When we tracked the financial trail, we were shocked to find that once a patient acquires an infection in the hospital, the hospital loses its entire margin.

JHC: In one of your reports, PRHI writes that successful hospitals avoid “the fatal flaw of most organizations: to assign Ôquality’ to a Ôquality department’ or safety to a Ôsafety officer.'” Instead, facilities employ experts to offer technical assistance to the frontline workers, who are expected to “own” the work of continuous improvement. Can you describe how this plays out in the real world?

Feinstein: This gets to the core of who we are. It is the people who actually deliver care to the patients [who can make this work]. They probably make 100 decisions every half-hour Ð subtle decisions that have enormous implications on the outcome of care. And they can undo good intentions. They might decide to fix a problem without identifying it and getting to its cause, or to overlook a safety precaution because the system has made it difficulty to comply with it. It can be a decision not to communicate as clearly as possible with a co-worker.

In many hospitals, the quality and safety team are so far removed from the people doing the work that you have to laugh.

The other thing is that measurement has become the sacred preserve of [this team]. They keep data on errors and inspections very close to themselves. But the people who really should be collecting and using that data are the frontline workers. They should be asking questions like, “Did we get all of our patients to physical therapy on time?” Because, if they didn’t, some of their patients might not be able to get therapy; and if patients don’t get rehab, they may have to stay in the hospital longer. And that’s not good for them.

So in a perfect system, the team constantly measures its performance and knows what helps them get better and better in meeting patients’ needs. And they share their discoveries. If everyone owns the work, you can vastly improve quality and outcomes. And it’s all tied together. The best practices Ð those that are error free Ð are also efficient. They’re not wasteful. In the medical-surgical unit we designed at the [Veterans Affairs] hospital, you can see how all these things come together: in a precise and efficient workforce focused on delivering quality care and the outcomes of every patient.

There are no shortcuts. But when you see it working, it’s like watching a ballet or symphony. It’s much better than the chaotic settings of so many units, where everyone is improvising. Those workers may feel good at the end of the day; they found 100 ways to overcome the barriers to provide the best patient care they could. But you want to be in a setting that helps you succeed.

JHC: Have you examined the potential impact of medical technology on patient care?

Feinstein: In such a high-tech setting as a hospital, increasingly, you can’t ignore technology. Human factors engineering helps minimize the potential harm of new technology, and [helps demonstrate to caregivers] how you can use it as a pathway to better outcomes. This is a hugely untapped area.

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