October 13, 2006 | Volume 3, Issue 2
Dr. Karen Feinstein
President and CEO, The Jewish Healthcare Foundation
Dr. Karen Wolk Feinstein is President of the Jewish Healthcare Foundation (JHF) of Pittsburgh, and founding Co-chair of the Pittsburgh Regional Health Initiative (PRHI). Her efforts to drive performance excellence across the region and to bring fresh perspectives to the health-related needs of under-served populations have attracted national interest and honors. The Heinz School Review spoke recently with Dr. Feinstein about the “Perfecting Patient Care” model, an innovative approach to achieving performance excellence in healthcare.
HSR: You helped co-found the PRHI based on engineering and “business case” principles. Can you elaborate on the major achievements of this initiative?
Feinstein: I would like to think that we helped ignite a new reform movement within health care. We weren’t looking for national policy solutions. We were looking at what happens at the point of care – when care is delivered to patients. We said that if that goes wrong, everything else goes awry. If it’s not delivered with best practice care, efficiently, and safely – if these things aren’t in place, you’re going to be paying for all the wrong things and actually harming people. Our idea was to bring the revolution down to the point of care where worker touches patient and to get out of the policy realm. We asked people to set their sights high. We started with eliminating all hospital-acquired infection. That was pretty revolutionary at the time, but we said you could do it and you should be aiming for that. You may not do it the first year or the second year – maybe not the eighth year – but eventually you should be able to figure out how to eliminate something that causes so much harm and death. And, you know, we were off. That was the beginning of changing people’s mindset of what needed to be done to deliver care well in a less costly manner.
HSR: Have you encountered any resistance in implementing this innovative system?
Feinstein: Well we encountered enormous resistance, which is to be expected anytime you turn the status quo upside down. Of course there were physicians who said that hospital-acquired infections are inevitable and that you can’t do anything about those little critters, but we always had other physicians who would rise up and say, “No, we can do something.” We’ve proven that it’s preventable here and there in units that are precise, and we’re diligent about following every protocol. We’ve proven that you can halt the spread of infection – it should be universal everywhere. So for all the people who were naysayers or working against this kind of change, we’ve always had champions. I think it’s been most upsetting at times to people who have a large financial stake in the current order. We have a very perverse reimbursement system and that’s very troubling because we pay physicians and hospitals to harm people. And reimbursement goes way up when people are harmed in the course of their care. On the other hand, if they went looking for money to deliver good preventive services or to build into their program the kind of staff training and retraining and buying the right equipment and supplies to deliver care as perfectly as possible, no one covers those costs. So the current rules actually work against the work that we’re doing. If you say that 30% of the money we spend on health care is wasted for redundant, unnecessary, or harmful procedures, no one will bat an eyelash. The inefficiencies are just huge.
HSR: So how did you go about identifying the operational inefficiencies that needed to be tackled first?
Feinstein: We had to get out of the clouds. In my training at Brandeis, I focused on labor economics and so I’m used to looking at the world from way out – on top of a building looking down. We had to get out of the top floor and down to the ground floor and go to the point of care. And you start with something – i.e., hospital-acquired infection. We started to closely examine all the pathways for infection that were open and not closed and started working with teams to eliminate every pathway for infection following best practice protocols. And as you do that, you learn a lot. You can start to see all the places with room for improvement. We developed our own quality engineering program that we call “Perfecting Patient Care” built on Toyota’s principles. So we actually had a quality engineering approach that we could teach in our own university and then apply on site with our own coaches to help various teams choose some area of focus and identify the gap between best practices and what was actually happening.
HSR: Who were these teams comprised of and on what level did you direct your intervention most?
Feinstein: Well, if you stay at the point of care, you’re talking about a clinical team – people who are most closely connected to the care of patients. It only really works long-term and is sustainable if you have the support of administration and of middle managers, but we don’t begin there. We look for their blessing and their invitation to come in and work with frontline staff – which is really essential – but, eventually, as the frontline staff start removing every pathway for error and inefficiency and applying all the best practices, they really do need the active endorsement and support of people throughout the institution. So eventually you have a whole line of support that is essential – you can’t just rely on the frontline teams, they will eventually need a whole line of support throughout the organization.
HSR: One of the goals of the initiative is zero medication errors, which is quite an ambitious goal. What makes the organization place a higher priority on this target than others?
Feinstein: We thought of a number of things we could have focused on such as bedsores, falls within health-care institutions, and medication error. But the idea is to start somewhere because it’s so overwhelming. So we started with infection because if you get it right, you get patient outcomes that are outstanding. So infection made a lot of sense, but we do other work. We do work in diabetes and are moving into addiction. We have done work on depression and in pathology. The idea is to get teams to collaborate on identified improvement targets. And when you can get the teams being creative and focused on improving something, they learn a lot in the process that they can then apply in other conditions – so in an interesting way it doesn’t matter where you begin. Once people get comfortable with rapid problem solving and the identification of all the opportunities for improvement, you start them on a new cycle of improvement that doesn’t stop. For example, our work in pathology led from one improvement to another. We wanted to do improvement work in the reading of a pap smear slide so that we had better accuracy. We discovered that it wasn’t the readings [that were leading to inaccuracies] but the sample itself – people were taking the specimen from the wrong place. It’s kind of a “see one, do one, teach one” in pap smear collection – the training doesn’t run very deep. So we had to get out of the path lab and work with a really talented gynecologist who was willing to be the test site and he realized that, initially, about 9–10% of his smears were from the wrong place – and this was an experienced gynecologist. Just by being more diligent, he was able to bring it down to 3% on his own. One thing led to another – eventually the team that started just by looking at a better reading of the slides went to collection of the specimens and have now moved on to how you can more creatively and effectively train people to collect specimens for pap smears. One thing can lead to another as you seek better and better outcomes for patients.
HSR: How successful is “Perfecting Patient Care” across other organizations?
Feinstein: Well, I can’t tell you how hard the spread of good ideas is – the joke is that the only things that don’t spread in a hospital are good ideas. The contagion of good ideas is a major challenge. People always ask me, “What hospital should I go to?” and I say to them, “You’re asking me the wrong question.” Ask me what unit you should go to within any hospital because hospitals can have very different patient experiences in quality from one unit to another. A lot depends on the unit leadership——the nurse manager; if there’s a physician, the physician in charge. Those who are really diligent and dedicated to good patient outcomes get better patient outcomes. It’s very hard for us for some reason to transfer best practice innovations. It’s very slow. Some people in health care say that it takes about ten years for an innovation to really spread across systems. We don’t yet have any magic for that. I will say that in infection control we brought a lot of attention to central-line infection – a particularly deadly kind of infection. Almost all of them originate from something that went wrong in the hospital stay. So in central-line infection, because we rallied a whole region – 40 hospitals around it – we had amazing spread so that we were able to reduce central-line infection in the region 68%. That’s an excellent example of spread but it doesn’t always happen. You need to have those data in front of people and people getting better and better at sharing best practices and then more and more teams saying we don’t want to be left out – we want to be part of the solution.
HSR: In addressing these problems, then, do you really have to focus on an individual unit or can you address it from the top down?
Feinstein: That’s an excellent question and I wish I had an easy answer. Virginia Mason Hospital and Medical Center in Seattle has done a wonderful job of a top-down approach. Their top executives are all trained in Toyota production principles along with a number of their top managers but they still admit that when you go out to a hospital you see many units and many departments where it hasn’t really extended its reach yet – you don’t feel a big difference when you’re out in those units. We start at the bottom. We have units that are phenomenal; it hasn’t reached up to transform an entire institution. I don’t have an easy answer. I would say that right now there’s a national reform movement under way such as the “100,000 Lives Campaign” where a lot of hospitals had to fess up to the fact that they had a lot of problems that needed to be fixed – that was a big step. Even maybe our national associations are coming along and saying, “We can’t keep fighting this, we have to join it and become part of the solution.”
HSR: So is there any way to address this from a policy approach at a national level?
Feinstein: Well, I wrestle with that all the time and at the moment – because I took Psych. 101 – I’m into the “pellet” theory: that reimbursement reform would mean a lot. If we understand what the best care involves – which might mean relying on new devices, new supplies, or staff training – and if we knew what it took to deliver the best care, we would have a financial incentive to do that. At the same time we were carefully – because you don’t want to upset the whole system – removing financial incentives to do the wrong thing. You want to lower the disincentives to good care, while you are raising the incentives for good care so that I’m now, as a provider or a health professional, getting paid more and more to do the right thing.
HSR: Is there room for any technological solutions in PPC?
Feinstein: We started out saying “don’t focus on tech, don’t focus on policy,” because that is where everyone was focused. There was some idea that if you gave everyone a handheld PDA they would no longer have a medication error. There is no doubt that it is the way of the future and CPOE, computerized physician order entry for medications, is likely to screen out a lot of errors, particularly those that come from misinterpretations of bad handwriting. Personal health records, having an electronic medical record that was available, having inter-operability among your data sets – these things are all tremendously helpful, even Stentor, the ability to send radiology pictures via that internet and have a high degree of accuracy, all of that has been a great step forward, there is no doubt. The point that we try to make often is that even with the best technology, if you do not have good interpersonal teamwork, good handoffs, good communication among all the key players, high standards for everyone who touches patient care from admitting to housekeeping to the clinical team, you will never get the full value of the quality you are capable of administering. So, technology is an important component and policy change can be an important component, but none of them can replace the value of a well-trained team dedicating themselves to the patient’s well-being.
HSR: How much of that goes back to proper training in nursing and medical schools?
Feinstein: You talked about technology – one of the biggest breakthroughs is the simulator, these really sophisticated simulators, and I will say that the University of Pittsburgh Medical Center has one of the best simulation centers in the country. The more our nurses, physicians, and other health professionals are trained in teams on simulators, and go over and over the same intervention while measuring their performance and also following a curriculum designed to improve it, the better they are going to be at doing the hundred interventions and dealing with all the complex equipment now that is in front of them. There is a whole new revolution in healthcare education that needs to take place for us to institutionalize the kind of quality engineering that we are importing from the outside into teams that are ready to improve. This would be helped immeasurably by changing health professional education.
HSR: Have you found that socio-economic issues come into play in your work?
Feinstein: There is no doubt that in most conditions, there are disparities of care that are social, economic, racial, [based on] gender – you can touch them all. The hardest thing to communicate is will; I do not know how to instill will in people. I meet many health professionals that are so outstanding because they have a will to be outstanding, they have a will to be sensitive, they have a will to deliver the best care to every patient, and they have a will to constantly explore the frontiers and to acknowledge the limitations of what we know. I see a lot of people who don’t. Patients are victims of those without the will. If I knew how to instill will…if there were a vaccine, I would make sure that everyone gets inoculated.
But a lot of these issues are not insurmountable. I like the idea of continuing education. I hate when we have to force it on people. I want them to come seek it. I go through a lot of hospitals and I see: “Mandatory cultural diversity training will take place at 10:00am Monday morning!” And I think, “Oh damn, wrong direction again with ‘mandatory training.’” If you don’t want to go, if you don’t care about your patient, darn it, I don’t know if that mandatory 10:00am training is going to do it. It’s a real dilemma – how do we get people in health professions from the time they enter to be really excited about the mission they are undertaking and the responsibility they are undertaking? How do we develop in them the passion for the fact that they have signed on to care for human lives, and to hold in their hands the well-being and the whole life experience of another person? I don’t know. But we have to be able to do a better job. Particularly when I hear from certain segments of the AMA, I know we must be able to do a better job.
HSR: Would you give any advice to graduates of the Heinz Health Care Policy and Management program who are just entering the healthcare arena?
Feinstein: One – go and observe what is happening with a skilled clinician. There is no substitute for being on site at places where care is delivered. To have your eyes opened by people who can help you see better all the opportunities for improvement and ways in which our workers, which are such a scarce and valuable resource, are and are not well-employed during their daily work. I would say go and see it.
Second – don’t read a lot of stuff that is ten years old. There is good stuff coming out now all the time. It is happening so fast. Atul Gawande, who is just the greatest, I would read everything he has written. He is a physician from Boston who just got a MacArthur genius award. It’s one of the more exciting awards in my mind they have ever given. He is on the cutting edge. There are a number of things now that I think will open your eyes to all the possibilities.
Don’t be confined by healthcare as it is! Start to think of healthcare as it could be, this is a wonderful time for visioning, and utopian thinking, because it is possible. We should have utopian thinking. I do worry that a lot of people who teach – maybe sometimes they teach for too long, or the textbooks are outdated, or the articles in your bibliographies are bemoaning something and coming up with the wrong solution. But there is good stuff out there now that I would definitely focus on. Michael Porter’s work, coming out of Harvard is very exciting, and anything Atul Gawande writes, certainly The Bell Curve. Any of his articles in the New Yorker are just spectacular. You may have to carve your own way, the path that is handed to you by BIBs that are five years old are not going to get you to where you need to be.