Appendix A-3: Case Study: Pittsburgh Regional Health Initiative

The Quest to Bring Big Ideas to Life

Introduction

"Two approaches distinguished the Pittsburgh Regional Health Initiative (PRHI) from the start: its commitment to the theoretical limits of performance—the goal of 'zero'; and the application of Toyota/LEAN principles to health care."¹ These innovations began with creative "what if" thinking and developed through persistent leadership grounded in leading business practices. Along the way, PRHI made important links between different domains: health care, nonprofit foundations, government, and for-profit industries. This resulted in powerful impacts on health care delivery that are now being leveraged on a national scale.

This case study explores how PRHI applies art and science to find new connections that deliver meaningful results, which in turn build sustainability. "It's a never ending quest," said Jack Krah, executive director of the Allegheny County Medical Society and PRHI Leadership Obligation Group (LOG) member. "Successful collaboratives require commitment and tenacity. The work may be organized around specific projects, but the true leaders and innovators view it as a lifelong commitment."

About This Case Study This case study is part of a technical assistance program on sustainability developed by the Agency for Healthcare Research and Quality (AHRQ). The goal of this program is to support Community Quality Collaborative (Community Quality Collaborative) leaders and members in defining strategies that will lead to productive and financially sound collaboratives. This program explores the intersection of the science of organizational effectiveness such as models, tools, and proven examples-with the art of collaborative success, reflected by passion, creativity, and exploration. Each of the three case studies highlights a successful collaborative organization, focusing on the leading practices that have enabled that organization to grow and thrive. The case studies were prepared through interviews with staff and stakeholders, review of documents provided by each organization, and online research. This case study includes the following sections: Overview of the business model that supports PRHI. Discussion of leading practices, with examples of their application. Insight into PRHI's strategies for the next stage of the organization's development. Suggested next steps for Community Quality Collaboratives. This information is also summarized in the Sustainability Program Overview for Community Quality Collaboratives.

Powerful lessons may be learned from looking behind the scenes at the Alliance's Community Checkup, which while it is a significant achievement also presented significant challenges. It highlights the blend of art and science that leads to sustainability.

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Turning Big Ideas Into Reality: Applying Systems Thinking to Health Care

PRHI grew from an unusual seed. Its history provides insight into how collaboratives may leverage market opportunities and business viewpoints. In 1997, the Allegheny Conference on Community Development-a civic organization composed mostly of CEOs of the region's leading corporations-convened to advance the competitive position of businesses in the region. The group "came to recognize that health care had eclipsed steel manufacturing as the region's largest economic segment. That the region's leading economic driver should be responsible for millions of dollars in escalating employer costs, yet deliver less-than-stellar patient outcomes concerned members of this ... civic organization."²

As a direct result of this realization, all of the business members at the conference contributed to the initial funding for the PRHI, originally set up as a Working Together task force. This, in turn, was supplemented by grants from the Robert Wood Johnson Foundation and the Agency for Healthcare Research and Quality).

One of PRHI's significant contributions has been to bring workplace engineering to health care, through the insight of Paul O'Neill, who was at the time CEO of Alcoa and later U.S. Treasury Secretary. "O'Neill believed that the Alcoa Business System, which followed the tenets of the Toyota Production System, could translate reductions in waste and error to the health care industry..."³ PRHI developed the Perfecting Patient Care^sm (PPC^sm) program to apply the Toyota principles to health care.

In the book, The Pittsburgh Way to Efficient Healthcare, a number of these projects are explained with helpful details about both the art and science that led to successful improvements.

Quick Facts4 Mission: The Pittsburgh Regional Health Initiative, or PRHI, is an independent catalyst for improving health care safety and quality in Southwestern Pennsylvania. It operates on the premise that dramatic quality improvement is the best cost-containment strategy for health care. Launched: 1997. Chief Executive Officer: Karen Wolk Feinstein. Staffing: 14 full-time equivalents. Participation: PRHI was the first regional consortium of medical, business, and civic leaders to address health care safety and quality improvement as a social and business imperative.

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Business Model Insights

PRHI is in a unique position with respect to funding. According to PRHI Chief Executive Officer Karen Feinstein, the organization is privileged to have the support of the Jewish Healthcare Foundation. This relationship provides not only recurring funding, but offers improved access to project partners and resources as well.

For example, the Foundation supports Health Careers Futures, a sister group to PRHI with a different but compatible mission. Health Careers Futures focuses on the supply and demand for health care workers in the region, with the goal of reducing "the number of vacancies by increasing the quality of applicants and the retention of incumbent workers."⁵

Organizational leaders know how much time and energy goes into securing funding and managing cash flow. Successful leaders also know that the key is in finding the right sources of funding. As stated in the book, Forces for Good: The Six Practices of High Impact Nonprofits,"... sources of support may vary, but successful groups integrate fundraising with their strategy, and they find ways to diversify these sources over time to reduce their financial risks."⁶

Financial Model

Annual funding for PRHI totals $2.5 million, with more than half of the funding provided by foundations. These funds, in turn, are allocated to programs, with nearly half budgeted for online education and social marketing. As illustrated in the charts below, the prevalence of foundation funding enables PRHI to make strategic decisions about the programs it will pursue.

Note: Administrative and overhead costs are allocated to each program.

For more information about how funding sources align with program delivery, go to the Sustainability Program Overview for Community Quality Collaboratives.

Tomorrow's Health Care

PRHI is developing a Web-based learning network dedicated to health care quality and safety. Tomorrow's HealthCare (THC) will create communities of learners and change agents, providing them with relevant information and a "space" to gain insight into process improvement strategies, and share results of demonstrations, case studies, breaking news and data relevant to their areas of interest. A significant portion of the budget is dedicated to developing this network, while sustaining the established, successful programs, such as PPC^sm.

THC's mission is to provide on-demand and relevant information, learning, application, coaching, and networking tools that improve health care systems and quality of care, advance workforce development and retention, and enhance institutions' and professionals' capacity for process improvement implementation, measurement, and maintenance.

Governance

PRHI is organized under a 23-member board of directors. Appointees are approved by the Jewish Healthcare Foundation. The board meets every other month for two hours. According to Feinstein, board meetings often run over, suggesting that more time with the board would be useful. However, she recognizes the extensive commitments of the leaders on the board and appreciates the time they commit to PRHI.

PRHI also operates a Leadership Obligation Group, or LOG. The name reflects the fact that it is made up of leaders from different stakeholders, all of whom have a role to play in producing and an obligation to produce a high-value health care system.

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Application of Leading Practices

PRHI began from a unique starting point with the assessment of market forces in the Southwestern Pennsylvania region. This perspective continues to influence how PRHI evaluates and responds to its market, keeping its finger on the pulse of the stakeholder community. The following leading practices, which have enabled PRHI to deliver value and expand over the past 10 years, provide insight and tools for Community Quality Collaboratives to develop sustainable models.

Note: The Sustainability Program Overview for Community Quality Collaboratives defines seven Leading Practices that are common among successful collaboratives. Each case study highlights a subset of those practices. For more information, please see the Overview document.

Demonstrating Tangible Value

PRHI has been a pioneer in developing hands-on methods for directly impacting health care delivery. The PPC^sm program has been delivered to several thousand participants, and has resulted in substantial, documented improvements in clinical care.

In developing the PPC^sm methodology, PRHI made critical adjustments to meet the needs of its stakeholders, including:

• Understanding the market: In the beginning, the training was led by PRHI facilitators. However, it was difficult to introduce outside consultants as the "go-to-expert" in a health care setting, particularly if their background wasn't clinical. After observing the sessions and hearing participants' feedback, the role of facilitator was shifted to an employee of the health care provider organization. When the focus shifted to developing internal champions, desired changes happened faster and more effectively from the inside, with a PRHI coach onsite or in the wings.
• Tuning the program to participant needs: Clinical professionals often cannot break away from their practices to attend a four-day "university" to learn new skills. Therefore, PRHI made the PPC^sm program more accessible by delivering Web-based training.

As a result of these focused efforts, the PPC^sm University generates more than $250,000 in recurring revenue per year.

Establishing a Transparent Management Style

According to the National Networking Conference, "Coalitions must step up to the challenge of measuring and demonstrating their own effectiveness, defined in terms of population-level improvement."⁷

PRHI applies this practice in its clinical improvement projects, as well as in the day-to-day management of the organization. For example, early on, the results of workgroup efforts were shared only within the team that worked on the project, which limited the effectiveness and the impact of the program. This practice is evolving to an open and transparent approach to sharing appropriate data regionally, and building on what is happening nationally.

One of the most powerful examples of this concept is the successful progress PRHI has made toward the challenging "goal of zero." "Of all the hopeful ... ideas to come out of PRHI in its youth, none provoked more controversy and outright ire than the 'zero goal. '"⁸ Taking this approach required that a challenging question be asked: What rate of error is acceptable to the patient? The answer, as demonstrated in a focused pilot project on central-line infections in the intensive care unit (ICU), is that zero errors are acceptable, and in fact, this goal is achievable. For more than 13 months, no central-line infections were reported in the studied units.

Examples of other PRHI impacts that demonstrate transparency and a focus on data:

• The PRHI methodology resulted in an 85 percent reduction in methicillin-resistant Staphylococcus aureus (MRSA) infections in the post-surgical unit of a Pittsburgh Veterans Affairs (VA) hospital.
• The team that tackled MRSA at the VA hospital proceeded to apply the methodology to other problems, which resulted in additional quality and efficiency gains, such as improving on-time delivery of medications by 10 percent to reach 99 percent performance.⁹
• Processes for diabetes care at the VA Pittsburgh Healthcare System were significantly improved, including a 68 percent reduction in patient wait times, 20 percent increase in scheduling capacity, and more comprehensive care through a team approach. Additional data on patient outcomes will be published in an academic report.¹⁰
• By standardizing ICU nursing protocols that enable nurses to start common procedures immediately, the average length of stay was reduced by 2.2 days, resulting in $1.5 million savings for bed days alone.¹¹

PRHI recognizes the next challenges in applying this practice: to extend the learnings beyond "islands of excellence" to a very complex hospital environment; and to continue stretching the goals of PRHI in a similar vein, extending performance, innovation, and transparency from a fact-based foundation.

Employing Rigorous Prioritization

PRHI's leaders have learned to apply prioritization in an iterative process. "There is no substitute for choosing the right projects," Feinstein said. For example, the vision to demonstrate a strong return on investment by reducing hospitalizations and emergency room visits, while tackling chronic disease, presented a field of options. When weighing a narrowed list of alternatives, PRHI chose to first tackle chronic obstructive pulmonary disease (COPD) before diabetes in order to demonstrate value. While considering previous work that demonstrably improved the care of persons with diabetes, the longer timeline required to show results in the treatment of that condition led PRHI to first tackle COPD.

Jack Krah, executive director of the Allegheny County Medical Society and PRHI Leadership Obligation Group member, also noted the wisdom of this approach, highlighting the need to get early victories to demonstrate value to stakeholders and advising, "Don't try to tackle everything at once." Furthermore, he recommended actively involving those most impacted by proposed changes. For example, PRHI asks clinicians to identify the biggest issues in their environments, an approach that ensures that PRHI knows the market and focuses on delivering value to its stakeholders.

As an example, PRHI's work in reducing infections has been "rewarding beyond belief," according to Feinstein. By simply and methodically removing obstacles, PPC^sm teams are making the lives of health care professionals less chaotic so that they can concentrate on delivering perfect care. Applying the same principles, Feinstein seeks to remove external distractions from her PRHI team so they can concentrate on the job at hand.

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Life Stages: What's Next for PRHI?

The challenges and opportunities facing each Community Quality Collaborative will vary, depending on its stage of development and local market forces. PRHI has solidly established itself and its mission in the region. Its current strategic plan focuses on refining and extending the first decade of success.

Life-Cycle Phase	Common Activities	Key Questions	Desired Outcomes
Vision	Defining goals Assessing market forces Recruiting leaders Securing initial funding	What are we trying to accomplish? Who will help us get there?	Clear goals High energy and engagement Initial funding
Growth	Demonstrating value Recruiting members Building strategic plans Leveraging and extending funding	How will we get there? What do our stakeholders expect?	Early “wins” – producing recognizable value Roadmap for growth Committed membership
Establishment	Institutionalizing value Executing plans Retaining members Building infrastructure	Are we on track and delivering value? How do we sustain commitment and success?	Recognition as a leader and trusted source Sustainable business plan Reliable funding
Extension	Delivering recognized value Assessing results; benchmarking Adjusting plans and structure	What is working or not working? How has the market shifted?	Continued demonstration of value and recognition New perspectives New or renewed funding
At times, organizations are challenged by events and circumstances that force significant regrouping and changes, which may be unplanned or outside of a typical life cycle.
Rebooting	Responding to significant shifts or negative events	What went wrong? How will we adjust and continue?	Renewed vision Practical plan of action Retaining critical leaders, members, and funding

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Vision & Growth Stages: Early Challenges

Looking back, Feinstein observes that the organization may have grown too fast. "We had a big budget and lots of staff, while we were still feeling our way." This did not deter the group from tackling knotty issues that were highly controversial, such as infection and medication errors occurring in health care and the cost associated with them. She notes that persistence was a core competency in those early days and credits active leadership, particularly from Alcoa's O'Neill for having a vision combined with the tenacity to drive breakthrough successes.

Extension Stage Strategies

PRHI leaders and members recognize that they have signed up not just for a project, but for an ongoing process. To continue its successful journey as an organization, PRHI is applying the following strategies:

• Challenging themselves to demonstrate an impact on health care premiums: Feinstein recognizes that until a substantive financial impact is demonstrated, their efforts may be viewed as merely "pleasing charitable ideas." The health care quality movement needs to demonstrate increased value to the business community in order to continue building and thriving.
• Leveraging business partnerships: PRHI is in the process of creating a partnership with a for-profit LEAN engineering organization in Nashville that will extend PPC principles to have a much wider impact. In building this relationship, it was critical to find a good match in vision, organization, and skills.
• Finding ways to integrate and extend the PPC^sm methods beyond 'Islands of Excellence': Given the complexities of the health care delivery system, there are many more opportunities to target specific issues in health care delivery with the PPC^sm approach and to link them together throughout the system. For example:
  • One initiative will tackle the complications that substance abuse adds to chronic illness.
  • Another project seeks to demonstrate to insurers that paying for Chronic Care Model approaches, such as spending more time with patients, leveraging non-physician care managers, and initiating contacts other than typical office visits, will ultimately reduce the total cost of care by reducing hospital admissions.¹²
• Acting regionally and thinking nationally: All PRHI projects are designed to produce replicable models for transforming care throughout Pennsylvania and elsewhere in the country. PRHI has had a major influence in the state of Pennsylvania. For example:
  • Key items included in a recent sweeping health reform agenda were incubated in PRHI programs. Some were passed in 2007, while others remain on the agenda for 2008.¹³
  • PRHI plans to launch a Web-based virtual community to create a nationwide forum for providers and administrators grounded in the PPC^sm program.¹⁴
  • PRHI is working with other regional coalitions through the Network for Regional Healthcare Improvement and networking contacts. For example, they stay in close touch with a group in Iowa that is applying Toyota principles to quality improvement in health care.

Each of these strategies will contribute to the sustainability of PRHI, by demonstrating tangible value that clearly meets the needs and expectations of stakeholders.

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Next Steps to Build Staying Power in Your Community Quality Collaborative

Not all Community Quality Collaboratives start with the combination of resources that were instrumental for PRHI, such as a generous parent foundation and the experienced and visionary leadership to drive a substantial program like Perfecting Patient Care^sm. However, each Community Quality Collaborative brings its own unique blend of ideas and resources, and each can learn from practical techniques applied by other collaboratives such as PRHI.

As you build strategic plans that emphasize sustainability, the experience of successful collaboratives like PRHI may guide and accelerate your efforts as you:

• Fine-tune your efforts to the needs of your market: Pay close attention to what stakeholders say and do.
• Choose powerful initiatives from a menu of worthy possibilities: Use science to define the universe of options and art to determine which ones will have the most positive impact on the community and your organization.
• Develop ground-breaking approaches: Think outside the box to develop new approaches to health care problems.
• Demonstrate the positive impact and return on investment that your stakeholders require.

For more information, please go to the two other case studies.

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References

¹ Healthcare Quality: The History of a Movement. Page 4, in The Healthcare Quality Revolution: Celebrating the First 10 Years of the Pittsburgh Regional Health Initiative, Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative. March 14, 2008.

² Health Care Quality: The History of a Movement, page 4.

³ Ibid.

⁴ prhi.org

⁵ hcfutures.org

⁶ Leslie R. Crutchfield and Heather McLeod Grant, Forces for Good: The Six Practices of High-Impact Nonprofits, John Wiley and Sons, Inc., 2008, page 186.

⁷ National Networking Conference on Regional Healthcare Improvement, Summary for Participants, November 30-December 1, 2006, 4th page - not numbered.

⁸ Nadia Grunden, The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods, Healthcare Performance Press, November 2007, page xvi.

⁹ Program statistics provided by PRHI.

¹⁰ Program statistics provided by PRHI.

¹¹ Program statistics provided by PRHI.

¹² Healthcare Quality: The History of a Movement, page 9.

¹³ Healthcare Quality: The History of a Movement, page 9.

¹⁴ Healthcare Quality: The History of a Movement, page 14.

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