An RWJF Investment That Helped to Seed the Health Care Quality Revolution

RWJF helped the Pittsburgh Regional Health Initiative pursue its goal, says Susan Elster: to aim for continuous improvement in the pursuit of perfection.

It’s difficult to remember the world before the Robert Wood Johnson Foundation invested $1 million in a fledging health care quality improvement organization, the Pittsburgh Regional Health Initiative (PRHI). The year 2000 was a time when most thought that American health care (never mind its costs) was the best in the world. A time when, despite the steady health care-drive erosion of business’s bottom line, consortia of business leaders rarely included health care issues on their action agendas.

Before the RWJF investment, there wasn’t yet the language for labeling pervasive quality problems and rising costs as emerging from the same source. Few understood what would become PRHI’s mantra: that the joint pursuit of high quality and efficient health care was not only a social imperative, but also a business imperative.

This was a time before anyone thought that Lean industrial improvement methods could be applied to health care, or that pursuing perfection—the goal of zero errors—was more than far-fetched fantasy. It was a time when efforts to organize regional health care players to address the growing awareness of rising costs and substandard quality floundered for lack of neutral conveners to bridge often cutthroat provider competitors.

In Pittsburgh, PRHI founders Paul O’Neill and Karen Wolk Feinstein had managed to spark the interest of business and health care leaders, successfully conveying an idea that would eventually catch fire: namely, that a frontal attack on waste and error could simultaneously improve quality and reduce costs. They challenged this leadership to think beyond one-off, feel-good projects. Instead, the group thought big. They would tackle medication errors, eliminate nosocomial infections, and institute evidence-based care.

The RWJF investment–and meaningful vote of confidence–made it possible for these early PRHI champions, guided by PRHI’s Lean-based process improvement method, to aim for continuous improvement in the pursuit of perfection. And they made a difference.

Demonstration projects showed the power of Lean methods in the hands of frontline staff. PRHI led regional hospitals in reducing central line-associated bloodstream infections by 68% across 32 intensive care units. Quality experiments drove catheter-associated urinary tract infections down by 23-36%, and ventriculostomy-associated infections by 82%. Empowered clinicians reduced patient waiting time and pathology errors, improved diabetes outcomes and harnessed EHRs to improve patient care. Joining hands across the care continuum, providers reduced readmissions for patients with COPD by 44 percent.

Despite the seismic changes that have occurred in the past 15 years, the U.S. health care is still awash with error and waste. Employees continue to struggle with processes gone wrong–many of which continue to harm patients. PRHI has gone on to implore providers to apply Lean-based tools to full functionality–aiming for system change, rather than “spot repair.” In the words of a now famous Haitian saying, there are still “mountains beyond mountains.” But, following RWJF’s investment, there are now 40+ regional health improvement collaboratives like PRHI across the U.S. all working to find solutions to what ails health care. And they are supported by national policy makers who are finally acutely aware that healthcare quality is both a social and a business imperative.