What is Pursuing Perfection?

It is a national program of the Robert Wood Johnson Foundation designed to help hospital and physician organizations dramatically improve patient outcomes by pursuing perfection in all of their major care processes.

The mission of the Pursuing Perfection program is threefold:

• Achieve unprecedented levels of quality for large populations of patients across the care continuum;
• Build the internal infrastructure to deliver and sustain near-perfection levels of quality for patients; and
• Demonstrate that perfection-level quality is profitable for the organization.

So far, Pursuing Perfection grantees seem to be accomplishing that mission.

“They have learned how to achieve unprecedented levels of perfection,” said program deputy director Andrea Kabcenell. “They have reduced their mortality and complication rates. In addition, they have all made a good start on changing their infrastructure to promote quality, and the organizational leaders know what they need to do achieve perfection within their institutions.”

How has RWJF supported Pursuing Perfection?

RWJF has provided more than $20 million in funding for Pursuing Perfection since 2001:

• Over $6.5 million for technical assistance and direction of the program and communications activities to disseminate information on lessons learned and grantee outcomes
• Nearly $600,000 for planning grants to 12 organizations
• Over $15 million for implementation grants to seven grantees
• $900,000 in funding for an evaluation of the Pursuing Perfection program conducted by researchers at Boston University School of Public Health

Why did RWJF develop and fund Pursuing Perfection?

Each year, as a nation we spend more than $1 trillion on health care, yet the care provided to patients is far from perfect. In the mid- to late-1990s, it became apparent that health care quality in the United States had a long way to go. A 1999 report from the Institute of Medicine, To Err is Human, estimated the error rate in health care at over 2,900 per million—a rate that would stir public outcry in any other industry. At the Robert Wood Johnson Foundation, dialogue around improving the quality of health care in the U.S. centered on the idea of a sweeping transformation of the delivery system: embracing quality as a central business strategy.

In January of 2001, RWJF awarded planning grants to 12 organizations from a pool of 226 applicants and subsequently awarded implementation grants to seven of them. Grantees were challenged to pursue perfection across their entire organization.

There was no model for this kind of change in health care. “This was like the Lewis and Clarke Expedition,” explained Pursuing Perfection deputy director Andrea Kabcenell, R.N., M.P.H. “We were making the map along the way.”

Who are the seven Pursuing Perfection Grantees?

• Children's Hospital Medical Center, Cincinnati, Ohio
  • Adopted communications techniques used by the aviation industry to improve patient safety. The medical center's health care providers use standardized checklists in settings like the emergency room and operating room, to reduce the likelihood of confusion and errors.
  • Allowed children newly diagnosed with diabetes to use a new, flexible insulin therapy; today about 80 percent of patients just diagnosed with diabetes chose the new therapy that allows them to fine-tune their insulin dose, and the medical center supports them with education and training. Control of blood sugar has improved and patients feel a greater sense of control over their care: The parent of a 13-year-old patient commented, “When your child is diagnosed, you feel out of control. Being able to choose their treatment helps you feel a little more in control.”
  • Included patients on several new committees to improve care within the Cystic Fibrosis Center and established a set of promises made to patients and families, including optimization of lung function and nutritional status; As a result, the percentage of patients under the 10^th percentile for weight dropped from over 40 percent to less than 25 percent, more than 95 percent of patients receive flu vaccines up from 40 percent, and 85 percent of patients receive a respiratory culture on a quarterly basis up from less than 50 percent.
• McLeod Regional Medical Center of the Pee Dee, Florence, S.C. Increased the number of heart attack patients who received “perfect care” from 80 percent to 100 percent and reduced the mortality rate to about 4 percent, which is half the national average.
  • Initiated Patient Rounds for the hospital's senior leadership team – including the CEO, CFO, chief medical and nursing officers, and vice presidents of clinical effectiveness and patient care services – which allows them to speak with patients on a daily basis and learn firsthand about problems, issues, and work well done.
  • Engaged 175 of their physicians in the Pursuing Perfection initiative by serving on quality improvement teams.
  • Streamlined the R.N. hiring process at the medical center, strengthened ties with local nursing programs, created support groups for new R.N.s, and stationed a nurse retention champion on each unit, which resulted in a decrease in the nurse vacancy rate from as high as 25 percent on some units to under 3 percent and a recruiting cycle that dropped from 90 days to about nine.
  • Implemented a medication safety program that included strong commitment by senior management, medication tracking using handheld computers, physical separation of look-alike and sound-alike medications, automated medication ordering and dispensing, and decentralized pharmacists; the medical center was able to reduce the rate of harmful medication errors from over two per 1,000 doses in 2002 to less than one per 1,000 doses in 2004.
• Cambridge Health Alliance, Cambridge, Mass.
  • Improved care for children with asthma by implementing a patient registry and severity assessments, tailoring medications, regularly monitoring lung capacity, and creating a patient support system that includes the clinic, home, and school and an incentive program that rewards providers for improved care and outcomes; the percent of registry patients with hospital admissions or emergency department visits for asthma dropped from over 5 percent in 2002 to about 1 percent in 2004.
• HealthPartners Medical Group and Clinics, Bloomington, Minn.
  • Commissioned a theatrical production, “Fire in Bones,” and staged it for all employees to communicate to them the vision behind Pursuing Perfection.
  • Initiated a series of steps in the intensive care units and burn center to reduce or prevent ventilator-associated pneumonia and catheter-related bloodstream infections; the rate of ventilator-associated pneumonia dropped from 29 cases per 1,000 ventilator days in 1997 to 18 cases per 1,000 ventilator days in 2004 and the rate of catheter-related bloodstream infections dropped by more than 50 percent from 2002 to 2004.
  • Implemented a Planned Care Model within the medical group to care for patients with multiple chronic illnesses. A multidisciplinary prepared practice team assesses a patient's needs prior to the physician visit, during the visit, after the visit, and between visits; patients, providers, and staff report that they like the care model, and it is improving preventive and ongoing care for patients. More patients receive the age-appropriate screening tests, and patients with diabetes have healthy blood sugar, blood pressure and cholesterol levels.
• St. Joseph Hospital Foundation, Bellingham, Wash. The only Pursuing Perfection grantee that is a coalition of organizations, fully embraced patient-centered care. The Consortium includes St. Joseph Hospital (part of the PeaceHealth Health Care System), Group Health Cooperative, Community Health Plan of Washington, several primary care clinics, a cardiology practice, and the St. Joseph Center for Senior Health.
  • Invited patients to become members of the Pursuing Perfection multidisciplinary team. Their input resulted in the design and implementation of:
    • A patient-designed Web site, which includes vital information and tools for patients to manage their chronic illnesses and “become the most important member” of their health care team. For newly-diagnosed patients, the Web site offers testimonial from patients living well with chronic illness and links to resources that can support them in their efforts to self-manage their care.
    • The Shared Care Plan, which coordinates communication and information among all of a patient's health care providers. The Shared Care Plan includes in one, user-friendly document the patient's personal profile, health care team members, chronic and long-term diagnoses, self-management and lifestyle goals and action steps, treatment goals, names of prescriptions, medications and allergies, and advance directives. Patients can maintain their Shared Care Plan as either a Web-based document stored on www.patientpowered.org or a paper document that they carry with them.
    • The Clinical Care Specialist, who serves as a patient's advocate and guide. The Clinical Care Specialist is a nurse or social worker who is aligned with the patient and works with that patient over an extended period of time to provide education, support, and assistance in navigating the entire health care system. CHIC Special projects manager Mary Minniti explains the role of the Clinical Care Specialist: “The Clinical Care Specialist's job is to help get patients activated and engaged in the care partnership.”
• Hackensack University Medical Center, Hackensack, N.J.
  • Improved care and outcomes for heart attack patients by setting up mechanisms for patients to receive aspirin and a beta-blocker immediately, an EKG within 10 minutes of arrival, catheterization within 90 minutes, and a balloon dilation of the artery within 120 minutes; the medical center's mortality rate for heart attack patients is approximately 5 percent, significantly below the national average of 10.9 percent.
  • Reduced the average length of stay to 4.99 days, which is among the lowest in the state, by redesigning systems of care, including the emergency department, medication ordering and dispensing, and discharge planning.
  • Reduced the nursing turnover rate to 8.7 percent, which is less than half the national rate, changing the compensation system, initiating flexible scheduling, and building a team environment.
  • Initiated Multidisciplinary Rounds that bring together a team of caregivers including an in-house physician, advanced practice nurse, nurse manager, staff nurse, social worker, a case manager and sometimes a pharmacist to review patients' diagnoses, pending care issues, and discharge plans; the notes from rounds are kept in the patient's record. In an evaluation of Multidisciplinary Rounds, physicians reported that they are very satisfied with how the rounds contribute to patient care.
• Tallahassee Memorial HealthCare, Inc., Tallahassee, Fla.
  • Opened a Center for Chronic Care to improve the care and increase the continuity of care across inpatient and outpatient settings for patients with multiple chronic illnesses; care is orchestrated by the center's director, an internist and gerontologist. Among the center's patients, primary care physician visits have increased 250 percent, while inpatient days have decreased 40 percent, emergency department visits are down 37 percent, insurance claim costs are down 18 percent. In addition, the percentage of patients with their blood pressure under control doubled in one year from 40 to 80 percent and patients report improvements in their functional status.
  • With Rapid Response Teams and multidisciplinary rounds, addressed the higher than average hospital mortality that, according to a chart review, was the result of failure to communicate, failure to recognize when a patient's condition was worsening and take action, and failure to plan the patient's care; between 2001 and 2004, the hospital reduced its overall mortality rate by nearly 31 percent and reduced condition-specific mortality rates for heart failure by 62 percent, heart attack by 53 percent, pneumonia by 46 percent, and stroke by 41 percent.

  In addition, six international health systems self-funded their participation in Pursuing Perfection. They are:

  • The National Health Service, United Kingdom: Bradford community, North and East Devon community, Lambeth and Southwark community, Norwich and Norfolk community
  • City Council of Jonkoping, Sweden
  • Reinier de Graaf Group, Delft, The Netherlands

How does Pursuing Perfection fit with RWJF's overall goals andstrategies in the area of health care quality?

RWJF has a long history of investing in initiatives to assure that all Americans, especially those with chronic illnesses, receive quality health care. The Foundation concentrates specifically on redesigning systems to improve the quality of care—including standardizing quality measures within the industry and encouraging consumers and purchasers of care to hold providers accountable for delivering quality care. The goals and objectives of the Pursuing Perfection program are in alignment with RWJF's goals in the area of health care quality: Specifically, the program seeks to transform the delivery of care in hospital and physician organizations through dramatic improvements in all of their major processes of care. Grantee projects have engaged consumers as advocates for change and improvement. Patients sit on boards, participate on quality teams, and are a strong voice for process improvement. In addition, many grantees have worked to standardize their delivery systems—such as the automated dispensing of medications—and build consensus around measures for evaluating outcomes.

What Are Some of the Overall Lessons Learned From Pursuing Perfection?

• To transform the delivery system, senior leadership must support and drive the effort. Quality must become the daily work of the senior management team.
• Although there is no right path to perfection, an organization must first have a vision of perfection that is shared by senior leadership and staff and subsequently build a strategy for pursuing this perfection that includes project-level changes and infrastructure changes.
• Organizational transformation takes time. Organizations need to invest in learning the theory and practice of improvement.
• Hospitals and health care organizations need specific assets in order to raise the bar on perfection. They include clinical information systems, capacity to reach out for ideas, improvement skills, capacity to execute big system projects, and cooperation with and among providers.
• Even the most committed hospitals face significant challenges in changing health care beyond their own walls.
• Patient-centeredness is surprisingly powerful in its benefits. Even modest attempts to include patients in the redesign of health care processes resulted in significant improvements.

Program At a Glance

National Program Office: Institute for Healthcare Improvement
Cambridge, Mass.

RWJF Program Area: Quality Health Care

National Program Directors: Donald M. Berwick, M.D.; Thomas W. Nolan, M.D.

Program Web site

Other Pursuing Perfection Resources:

Modern Healthcare Series—A five-part series that appeared in Modern Healthcare in early 2005 examining in-depth the Pursuing Perfection initiative and the participating organizations, available at

Pursuing Perfection Video Series —a seven-part video series that draws on the experiences of seven major health care institutions participating in the Pursuing Perfection initiative, available for $450 for the set or $99 per individual tape.