This case study first appeared in the report Committed to Safety: Ten Case Studies on Reducing Harm to Patients by Douglas McCarthy and David Blumenthal, M.D.

Organization. Pittsburgh-based Allegheny General Hospital, with 829 beds, is part of the six-hospital West Penn Allegheny Health System and a partner in the Pittsburgh Regional Healthcare Initiative (PHRI). PHRI was organized in 1997 under the leadership of former Alcoa chairman and U.S. Treasury Secretary, Paul O'Neill, to achieve "measurable and sustainable improvements in health care on a region-wide basis" (Sirio et al. 2003). PRHI partners include 44 hospitals, four insurers, 32 health care purchasers, organized labor, and civic leaders.

Objective and intervention. PRHI seeks to engage hospital CEOs and physician leaders to endorse one guiding principle to alter the way people work: health care delivery must focus on providing perfect care to every patient.

Date of implementation. The Perfecting Patient Care System was piloted to improve patient safety in the medical ICU and coronary care unit at Allegheny General Hospital beginning in July 2003.

Process of change. PRHI adapted the Perfecting Patient Care System for use in health care from the principles of the Toyota Production System, a widely admired model for high-quality manufacturing at the Japanese car maker. The Toyota Production System consists of two essential concepts, according to the company's Web site:

• Jidoka or "automation with a human touch," which means that "when a problem occurs, the equipment stops immediately, preventing defective products from being produced."
• Just-in-time, which means "making only what is needed, when it is needed, and in the amount needed." This concept further implies "the complete elimination of waste, inconsistencies, and unreasonable requirements on the production line."

These principles can be roughly translated and applied to health care, as follows (Shannon 2004):

• The standards for performing work activities (such as intravenous line placement and maintenance) should be highly specified (not simply assumed), based on best practices, so that problems or variations from standards are immediately apparent.
• When problems (such as nosocomial infections) are encountered, they should be solved, in real time by the people doing the work, to determine root causes and employ countermeasures—or corrective actions—to prevent them.
• When workers cannot solve a problem, they invoke the "help chain" of expert support to solve the problem.

Under this approach, organizations create improvement teams (called "learning lines") in hospital units that work with team leaders to design solutions in real time. To support this effort, PRHI provides intensive education on the Perfecting Patient Care approach and has created a National Clinical Improvement Network to connect those working on patient care improvement through site visits. PHRI has also established safety event reporting using the U.S. Pharmacopeia MedMarx system for standardized medication error reporting and analysis, and a modified version of the Center's for Disease Control and Prevention's National Nosocomial Infections System to monitor nosocomial infection trends region-wide (Sirio et al. 2003).

After attending PHRI education, Richard Shannon, M.D., chairman of internal medicine at Allegheny General Hospital, challenged his hospital to adopt the Perfecting Patient Care approach, with an ambitious goal of completely eliminating a specific type of hospital-acquired infection—central-line-associated bloodstream infections (CLABs)—within 90 days in two ICUs. In order to achieve this goal, staff members would need to monitor the rates, root causes, and complications associated with CLABs and implement countermeasures to prevent CLABs based on evidence-based infection control guidelines and observations of central line placement and care.

Specifically, the steps in the process were to:

• cultivate the unit's medical and nursing leadership as champions for change;
• review past cases of infection to search for clues and common threads in causation;
• investigate the root cause of an infection as soon as it occurred;
• go to the frontlines to observe actual practices;
• generate improvement based on observations;
• standardize the process and communicate it to staff immediately;
• commission every clinician as a patient guardian;
• monitor for infections daily; and
• share success.

Root cause analysis found that femoral intravenous lines (i.e., inserted into an artery near the groin) had higher rates of infections than other sites, consistent with the findings of a randomized controlled trial (Saint et al. 2002). Countermeasures developed to reduce CLABs included:

• using subclavian approach (insertion near collarbone) whenever possible;
• removing femoral lines within 24 hours;
• prohibiting the rewiring of dysfunctional catheters;
• removing existing lines on patients transferred from other facilities; and
• asking whether the central line was still necessary.

The team also adopted other best practices, such as a standardized dressing change kit, and is starting to use an antimicrobial dressing when catheters remain in longer than two weeks.

Results. CLABs were nearly eliminated, falling 76 percent from 49 infections in 37 patients (5.1 per 1,000 line days) in the year before the intervention to six infections in six patients (1.2 per 1,000 line days) during the intervention year (Figure 11). Among patients with CLABs, the number of deaths decreased 95 percent and the death rate decreased 69 percent, from 19 of 37 patients (51%) to 1 of 6 patients (16%). Of the six CLABs that occurred, four were attributed to failures to follow specific guidelines.

A case-study analysis was conducted of the revenues and expenses associated with the care of six patients with CLABs, which found an average loss of $14,572 per case. This analysis suggests that the intervention saved over $500,000 and could save $1 million by eliminating the remaining 72 CLABs cases hospital-wide. Likewise, eliminating CLABs, ventilator-associated pneumonia, and antibiotic-resistant infections caused by methicillin-resistant Staphylococcus aureus could save a total of $10 million.

Lessons learned. Critical success factors included the following lessons: hospital-acquired infections are preventable; prevention is everyone's business; favor real-time observation over retrospective review; do not settle for the current best practice#8212;strive for perfection; and progress can be achieved rapidly and continuously using a scientific method.

The intervention showed staff that nosocomial infections are not inevitable and therefore not acceptable. "Where there is a will and a method, we can achieve transforming results," Dr. Shannon said. The hospital's management has been convinced of the efficacy of this approach after seeing the improvement in outcomes and the effect on the bottom line. Although not all physicians are fully engaged with the effort, "data is a powerful tool for overcoming that myth that physician independence is okay," Dr. Shannon said, referring to the teamwork approach that the Perfecting Patient Care approach promotes. Translating the infection rate into actual lives affected gives the numbers greater meaning and impact.

As a result of the initiative, the nursing team has developed a can-do attitude toward solving problems. Recently, an ICU nurse called Dr. Shannon to intervene when she could not get the radiology department to install a new intravenous line in a patient whom she feared would develop an infection. "That was the equivalent of pulling the 'andon cord' to stop the Toyota assembly line," Dr. Shannon told the Wall Street Journal (Wysocki 2004). Within two hours, the hospital's chief of radiology, Paul Kiproff, installed the new line himself.

Dr. Shannon believes that the same evidence-based approach can be applied to managing other diseases. "Making patients well is a lot more complicated than building a Toyota, but there is still a lot we can learn from the lessons that Toyota and others have built their success on," he said. Yet, efforts like Allegheny's remain "islands of success" and there is a long way to go before anyone can claim organization-wide excellence. He attributes lack of greater progress to failure of hospital leaders to claim the goal of eliminating nosocomial infections as a condition of meeting their commitment to operating a safe hospital.

Replication and related results. The Perfecting Patient Care approach is currently being adopted in all of Allegheny General Hospital's ICUs, which have already seen substantial reductions in CLABs and ventilator-associated pneumonia in the first three months of the intervention. Regionally, PHRI convened a group of infection control experts and other practitioners who developed a regional guideline, shared best practices, and recommended use of a kit of standardized supplies for safe central line insertion.

Recent findings and related efforts in this field include:

• Among the 29 PRHI member hospitals submitting data to a regional database, the rate of CLABs has decreased 55 percent, from 4.2 to 1.9 per 1,000 line days from 2001 to 2004. Hospitals have adopted approaches such as "zero tolerance" for handwashing violations and sending daily reports of infections to the hospital's CEO for review (PRHI 2004b).
• At the University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital, physicians in the medical ICU receive simulator-based training on safe central-line insertion, carried out using torso simulators in the University's simulation center. Residents may only insert a central line under the supervision of a simulator-trained physician. The UPMC Health System plans for all residents to receive this training (PRHI 2004b).
• At the Veterans' Administration Pittsburgh Healthcare System, antibiotic-resistant infections caused by methicillin-resistant Staphylococcus aureus have been reduced from about one per month to one per year in a post-surgical unit through education, reminders, and other low-tech strategies, like making hand disinfectant readily available, that remove barriers to complying with infection control guidelines (PRHI 2004c).

  Implications. In a recent invited commentary on hospital quality improvement case studies, Paul O''Neil and his colleagues at the PRHI offered these observations based on the experience of other high-reliability organizations that have made safety ubiquitous:

  Leaders establish quality and safety as preconditions of serving people and protecting the workforce. They accept responsibility for everything. They ask themselves whether they are getting all the information they need on what has gone wrong every day, and they ensure that the frontline troops have the permission and tools they need to solve each problem. Finally, leaders ask ceaselessly: How far are we from the ideal and what is the next improvement to move us closer to that ideal? (O'Neil et al. 2004).

  The Perfecting Patient Care System demonstrates that it is possible to translate the lessons learned from quality improvement in other industries to the health care setting. Using this framework for improvement, Allegheny General Hospital has replicated the results of Johns Hopkins Hospital and others who have significantly reduced or eliminated CLABs (see Case Studies 6 and 7). These experiences demonstrate that it is possible to meet the goal of providing safe health care so that patients are free from harm.

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  This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.