The Pittsburgh Regional Health Initiative wants to build a safer, more reliable health system. The organization, under the umbrella of the Jewish Healthcare Foundation, has made progress, but there’s a long way to go, says Karen Wolk Feinstein, Ph.D., president and CEO of the foundation and its two operating arms.
She helped create the PRHI in 1997 with then-CEO Paul O’Neill of Alcoa, who made the corporation a safety leader.
The group’s first effort was to reduce central line-associated bloodstream infections. Feinstein says they ultimately convinced 32 hospitals to sign on. Within four years, working with the U.S. Centers for Disease Control, these deadly infections went down 68 percent.
“That was pretty exciting because that launched us,” she says. “It was when people believed that the initiative could really make a difference.”
Over the years, the PRHI has moved from reducing medical errors and less than ideal hospitals practices, to a focus on keeping people out of hospitals, keeping people well.
The organization gained ground under President Barack Obama’s administration, which wanted to move away from fee-for-service payment, especially with Medicare.
The PRHI was written into three grants under the Center for Medicare and Medicaid Innovation, which gives funds for demonstrations in quality improvements. In addition, as a regional expansion center, the PRHI helped more than 900 physicians apply electronic records for meaningful use, Feinstein says.
The organization may be based in Pittsburgh, but it has a national presence. For example, the PRHI helped pave the way for pieces of the Affordable Care Act related to quality, safety, workforce, education and research — things not related to coverage. The organization even got to add items before the bill was introduced.
“We’re very proud of that aspect of the Affordable Care Act, and much of that is not going away,” she says.
Under the new administration, Feinstein hopes the health care system doesn’t slide back from its progress on quality and safety, but right now it’s hard to tell with everything so chaotic.
Obstacles to overcome
While the PRHI has made strides over the past 20 years, Feinstein says forward progress is slow. Reactions can range from indifference to outright resistance. The results have often been mediocre.
“Some of it comes from just a natural tendency to reject new ideas and to resist change,” she says.
Large institutions have built-in stabilizers that can keep them from responding.
“I wish I could say that all physicians believe that teamwork is critical, that they are professionals who always, always wash their hands and observe sanitary precautions. But they don’t,” Feinstein says.
In other cases, the health care providers like the ideas, but don’t want to do something that costs money — especially with already thin margins.
She says the PRHI has been working on payment reform for more than a decade.
People are paid for volume. But if infections, falls or leaving sponges or surgical equipment inside patients are reduced, it requires additional work.
“Although we have been successful the last 10 years in putting in light penalties for these events, I think sadly enough, people have learned to work around them by how they code and report error,” Feinstein says.
Also, once health care providers reach the middle of quality rankings, she says reducing the volume further to become the quality leader isn’t worth it. The exception is Kaiser Permanente, which follows a different payment system.
In every other industry but health care, quality improvements are accepted, Feinstein says. While many factors are at fault, the payment system is a big obstacle.
To change attitudes, the PRHI has tried a little bit of everything, such as graduate fellowships and teaching young professionals.
Most recently, it is taking a systematic approach. The organization has trained about 900 people, setting up a health activist network to keep them linked and working toward reform. The PRHI also created a group for women leaders called WHAMGlobal.
Some of PRHI’s coaching includes attempting to teach health care workers about Lean quality improvement techniques.
“At the hospital level, they don’t have a clue how to use Lean,” Feinstein says. “They think it’s a Band-Aid — literally, an elixir. You’ve got a sore throat; take a dose of Lean.”
In a health care system, they might hire someone to be the Lean person, but that doesn’t mean the C-suite has done anything different, she says. They don’t wake up and think, “How can we make sure absolutely nothing goes wrong today? How can we make sure every director and manager is aligned?” They just do a little training here and there.
“It’s not something you do when something goes wrong. Lean is how you get up in the morning and do your work, how you orient your staff, how you choose your managers — it’s a way of life,” Feinstein says.
The PRHI also recognizes champions in the different health care sectors, including giving awards to people with sustainable quality improvement projects.
“We’re trying to create, I joke, an army of the revolution of people who want to be quality leaders, who really believe that health care could be safer, more effective, more efficient and get better outcomes at lower costs,” Feinstein says.
The PRHI uses the expression, “eyes that can see.”
“Once you can see the dysfunction, and once you can see better ways of doing things, it’s pretty hard to keep doing the wrong thing and causing damage and harm to people,” she says.