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National series highlights efforts to 'remake medicine'

From the October ACP Observer, copyright 2006 by the American College of Physicians.

By Jennifer Kearney-Strouse

Three years ago, Richard P. Shannon, FACP, then chairman of the department of medicine at Allegheny General Hospital in Pittsburgh, set an ambitious new goal for his department's intensive care units (ICUs): eliminate catheter-associated infections.

Eradicating these infections, which the Institute of Healthcare Improvement has estimated to kill 28,000 patients each year, seemed an insurmountable challenge. But Dr. Shannon and his staff met it head-on by applying what is known in industry as the “Toyota principles” to medicine.

Working as part of the Pittsburgh Regional Health Initiative, a quality improvement consortium founded by Paul O’Neill, the former CEO of Alcoa and the treasury secretary in the first Bush Administration, Dr. Shannon and his staff succeeded in reducing catheter-associated infections at Allegheny General Hospital in the first year of the program from 49 to 6, and the number of associated deaths from 19 to 1.

Their success attracted the notice of producers from the Remaking American Medicine series, scheduled to air this month on PBS. The four-part series, of which ACP is a national partner, is designed to showcase important changes occurring in American medicine and trigger more improvements in the health care system. Dr. Shannon, now professor of medicine and vice chairman of clinical affairs at the University of Pennsylvania, is featured in the second part of the series, “First Do No Harm.” He recently spoke with ACP Observer about his work at Allegheny and how the methods used there can be applied at other institutions.

Q: How did you get involved in the Remaking American Medicine series?

A: We were engaged in the second year of a major effort to eliminate central line infections in our ICUs. We had received a lot of publicity about our early success because we were trying for the first time to apply industrial methods to the provision of care as it pertained to these central lines. We had reported some very startling results that were attributable to using principles that highly reliable industries use. I think it was the method that attracted attention as well as the rather impressive early results.

Q: How was your hospital involved in the Remaking American Medicine series?

A: The show followed us as we demonstrated the utilization of these industrial principles—what we call the principles of the Toyota production system (TPS)—to the delivery of what we hoped was flawless care around the placement and the maintenance of a central venous catheter. They filmed us as we were conducting our work rounds, our safety rounds. They literally spent time right inside the ICU seeing in person the complexity of care and how work standardization can lead to more reliable outcomes.

Q: When you introduced this goal of zero errors and zero hospital-acquired infections, what was the initial reaction?

A: Most thought I was nuts. Many of my colleagues figured that I was setting myself up to fail, and I think that the nurses with whom I had such a close working relationship really thought I had lost it. But I was able to see this problem with new eyes, having been empowered with these tools that I had learned from first-rate industries like Toyota and Alcoa. The hardest part was for people to understand the relationship between making a car or making aluminum and making a patient well. What we first had to prove was that we could apply principles of work standardization and principles of reliability to the provision of care, and that in doing so, unwarranted errors and defects would be eliminated.

Q: In the course of this program, you found that preventing infections helped patients and the hospital’s bottom line. Is that right?

A: That’s right. We did an analysis in which we tried to understand the complex relationship between these infections and hospital reimbursement. Our current health care reimbursement system is geared toward paying for activity as opposed to outcome. The more you do, the more you get paid, almost regardless of what the outcome is, good or bad. We were curious to determine whether hospitals and doctors made money when care was complicated by these infections.

Examining some 54 central line infections over three years, we found that the loss from operations on each averaged about $26,000. What we were able to demonstrate, in reducing the number of the infections, was a substantial improvement in the hospital’s operating margin. Over the course of two years, we’ve been able to save close to $1 million related to this project, and another $1 million related to similar work, which is now developed around the elimination of ventilator-associated pneumonias. The bottom line is that now, over a three-year period, we have improved the operating performance of the hospital by a total of $4.3 million. At the same time, we ended up saving 47 lives and admitting 388 additional patients to the ICUs, since individuals that previously were occupying those ICU beds with prolonged hospital stays due to preventable infections were no longer doing so.

Q: When you demonstrated that you could actually save the hospital money, did that make it easier to convince people that this was a good idea?

A: Absolutely. It was the demonstration of the economic impact of this that then led the management team at Allegheny General Hospital to really declare that these similar principles needed to be expanded and used in all our ICUs.

Q: In cases where the cost benefit isn’t as immediately apparent, are there still ways to improve quality, or is it harder?

A: I think it’s harder, because there isn’t a mindfulness among many health care workers of how chaotic systems can lead to unwarranted error. Nurses and doctors live in such a complex and chaotic delivery system that they rarely recognize a defect. As a result, defects on occasion can propagate into harmful error. By increasing the mindfulness of health care workers to observe variations in prespecified work designs, you can head off an error before it happens.

Q: How important is it to look at infections as soon as they happen?

A: Rather than waiting three months, we actually went to the scene and began to collect all the information we possibly could to try and absolutely understand what caused the infection. Once you knew the cause, you had two powerful new pieces of information. First, knowing what went wrong you could fix it. Second, in fixing it, you could declare that it would never happen again. Typically, we can’t figure out what went wrong and therefore it goes unattended, only to recur. Once our nurses and our doctors began to see that serious attention to these issues in real time resulted in substantial improvements, and that leaders like myself were engaged in this work as a precondition of the way we were going to operate in our ICUs, people began to understand that they were engaged in something very special.

Q: You’ve shared your approach to preventing infections with other hospitals in Pennsylvania and in several other states. Do you think efforts like these can be applied nationally, or is there too much variation among hospitals?

A: I think they can clearly be applied nationally. Two major improvement efforts have basically taken much of what we’ve done and implemented it. One is a consortium in Minneapolis called Safest in America and led by the Institute for Clinical Systems Integration in Minneapolis. The other spectacular example is the United Hospital Fund in New York City, made up of institutions that have basically taken the exact principles we used and applied them across their organizations with equally significant results. There are growing numbers of examples across the country.

Q: So it’s kind of like a revolution.

A: I wouldn’t exactly qualify it as a revolution yet, but what I think is most important is this provides the first opportunity, certainly in my professional career, where not only do patients benefit, but hospitals benefit and health care systems in general benefit. One is taking waste embedded in the care of patients with these infections and freeing it up so that the health care system, struggling under the weight of double-digit cost inflations, actually begins to use its resources more productively. If we can redesign systems to deliver more reliable outcomes, we can begin to use some of those precious resources to do some of the things all of us want to do: insure uninsured people, make sure that everyone that needs medications has medications, invest in the promising technologies which otherwise I’m not so sure we’re going to be able to afford. I think this constitutes a politically acceptable step in health care reform, where virtually everybody wins.

Q: Regarding the Remaking American Medicine series, what do you most hope that it will accomplish? What do you think would be the best thing that can come out of it?

A: The best thing that would come out of it, I think, is if more and more people, patients and their families, begin to realize that these conditions don’t have to exist, that they continue to bring pressure on their providers to make sure that they are fixing their systems to ensure that the risks of these infections are reduced. I hope people understand that they can help us in this regard by reminding of us things like washing our hands and safeguarding against the acquisition of such infections. I hope the health community sees this as a new approach to what has been an old and difficult problem. And I hope leaders in government see the opportunity to really begin to reward good outcomes rather than lots of different activities.

Remaking American Medicine is scheduled to air on Thursdays in October at 10 p.m. on PBS.

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