In Pursuit of Perfection

If the commercial aviation industry were like the medical care sector, says Mark Jarrett, MD, quoting a colleague, “planes would be 70 years old, there’d be no spare parts, and mechanics would be working on them while they’re in the air, 24 hours a day, seven days a week.”

The comparison is apt, says Jarrett, senior vice president and chief quality officer at Northwell Health, New York state’s largest integrated health system, with 23 hospitals and two medical schools. Jarrett notes that the safety record of airlines often is cited as a benchmark for hospital operations. In both, safe arrival at the destination — an airport, an outcome that’s the best medical science can offer — is the only measure of success. Any avoidable injury along the way, let alone any preventable death, represents an alarming and, at worst, tragic failure.

Airlines have the upper hand in a head-to-head contest. Last year, about 4.3 billion passengers flew safely on 46.1 million flights, according to the International Air Transport Association. Although there have been several highly publicized fatal crashes overseas in recent months, they’re anomalies. Not a single passenger fatality was recorded worldwide in 2017, and U.S. carriers recorded nine straight years, 2009-18, without as much as one. But upwards of 1,000 patients die each day in American hospitals, from medical misjudgments or mistakes.

“People are not 747s,” Jarrett says. “Doctors cope with a lot more variables than in the airline industry.”

But that doesn’t mean medical professionals who take care of human beings can’t be as meticulously close to error-free in the execution of their jobs as the pilots and ground personnel who make air travel reliable.

Or, at least, strive to meet or exceed that level of almost-perfection.

The Right Number

Sobering recent studies have found that more than half of all children and nearly half of all adults who see a doctor in the United States fail to receive the care recommended by medical science. Even when they’re admitted to hospitals, one in four suffers at least one care-associated injury during the stay. In 2002, about 1.7 million patients nationwide acquired a bacterial infection during hospital treatment. This was especially likely if they were in an intensive care unit. Almost 100,000 died.

“People used to say, ‘Oh, that can’t be helped,’ ” Jarrett says. They’d tick off reasons, from the procedural to the biological, that hospital-acquired infections pose an insurmountable risk.

By contrast, he continues, “today, we shoot for zero. True, we can’t reach that goal all the time. And we can’t always sustain it. But if you don’t use zero as your benchmark, you’re accepting mediocrity. If you’re really striving for excellence, your goal has got to be zero.”

And zero is attainable, he maintains.

“There are 35 [intensive care units] in our system, and once in 2018 and once in 2017, we went a month without a single central line infection in any of the 634 beds. Are we where we want to be? No. But we’re biting off chunks and we’re getting closer. We use numerators to measure the rate of adverse occurrences, and when you remember that each number in the numerator represents a human being, then you realize zero is the right number.”

The good news is that, according to the Centers for Disease Control and Prevention, U.S. hospitals overall have cut their health care-associated infection, or HAI, rate by half during the past 10 years. Nevertheless, despite steady progress, only a quarter of U.S. hospitals today meet the safety standard set by the quality-rating Leapfrog Group — a zero ratio for central line-associated blood stream infections. Even fewer, 15 percent, have achieved a zero ratio for catheter-associated urinary tract infections. About 800 hospitals were penalized by Medicare this year for excessive harms suffered by their patients.

That slow improvement discourages longtime health care quality banner-carriers. One, Donald Berwick, MD, a Harvard Community Health Plan pediatrician who co-founded the Institute for Healthcare Improvement in Cambridge, Massachusetts, in 1989 and still directs it. Another, Brent James, MD, a surgeon/oncologist and biostatistician who has trained thousands of physicians, nurses and administrators from around the world in best practices at the Institute for Health Care Delivery Research, which he directs at Intermountain Healthcare, in Salt Lake City, Utah.

Care Delivery Science

“I wish progress were faster,” Berwick acknowledges. “There’s a lot of information on the quality chasm, and much greater awareness of the degree of the problem. The defects are pretty well known. There are stunning examples of improvement. But on the larger scale, our health care system gets a C-plus at best.”

To be sure, James says, “the evidence is compelling that care delivery today is the best the world has ever seen. We routinely achieve very significant miracles. The life expectancy of a child born in 1900 was 49 years; by 2000 it was 77 years. That’s mostly attributable to the healing profession [and its adoption of the scientific method]. Something I really object to hearing politicians say is, ‘Health care is broken.’ I find that terminology offensive. To say something is broken implies it once worked perfectly … and there’s not a single example anywhere in the world of health care ever working perfectly — that is, broadly and correctly, on a reproducible basis.

“But that gets us to a deeper level,” he continues: “Understanding why.”

James points out four major problem categories:

• Wide variation in the type and quality of care given by individual doctors and hospitals. (“Who you see,” he says, “is what you get”).

• Inappropriate care (outmoded or dangerous therapies, or treatment in which risks outweigh benefits, violating the medical ethics principle to “do no harm”).

• Lack of attention to patient safety that makes medical misadventure itself the third leading cause of death in the United States.

• “Injuries of omission,” when best practices and evidence-based protocols are ignored.

“We can summarize those four as waste,” James says. “By my estimate, 65 percent of spending on health care overall is waste. But that presents a huge opportunity. The evidence is overwhelming that if you extract waste you can lower cost, and quality and cost are intimately related. As you improve quality, cost drops. The correlation is as real as we can imagine.”

Traditional medical science, he observes, which has given us 200 years of clinical miracles, has focused on understanding diseases and their causes, then devising targeted therapies. Now, he argues, it’s time to direct as much attention to a new branch he calls “care delivery science.” Given the complexity of modern American medicine, he notes — far beyond the capability of any single human mind to fully comprehend — that will require an organized approach, aided by technology.

“It’s the duty of every generation in the healing profession, part of our ethical commitment, to improve the state of the profession on our watch,” he declares. “The first step is to figure out where we fall short. The pursuit of perfection is the story of medicine going as far back as we can in the history of humankind. The pursuit of perfection is care delivery science.”

A Moral Duty

Galvanized by the Institute of Medicine’s landmark 2001 report, Crossing the Quality Chasm, which urged a fundamental reinvention of the U.S. health care system to achieve major improvements in the six key dimensions of safety, effectiveness, patient centeredness, timeliness, efficiency and equity, Berwick’s IHI put out requests for proposals, winnowed 240 applicants down to 13 health care organizations and enlisted them in a “Pursuing Perfection Initiative.”

Their touchstone, as described in another influential study at the Massachusetts Institute of Technology on “The Future of the Automobile,” was Japan’s Toyota Motor Corp. Its “zero defects” production system constituted a unique model of efficiency, waste-reducing Lean management principles and operations. Could the same principles be translated to health care?

The IHI’ s eight-year Pursuing Perfection Initiative fostered several powerful innovations. Among them were direct involvement of patients and their families in care design; development of frameworks for inclusion of senior leaders and boards of directors in strategic improvements; refinements in patient flow; bundling of key care processes that affect outcome; greater use of checklists; and “all-or-none” scoring of performance. For example, in pneumonia care, the number of patients eligible to receive at least one of four discrete elements of care is the denominator and the number of patients who actually received all of the care for which they were eligible is the numerator.

“The Pursuing Perfection Initiative was a challenge to organizations to step up, and the results were exciting,” says Berwick, who served as administrator of the Centers for Medicare & Medicaid Services in 2010-11. “There has been an attitudinal shift. We now look on any injury as avoidable. There’s a tendency in the political and clinical sphere to check boxes, to say a score is ‘good enough.’ But ‘good enough’ isn’t good enough. No matter where you are, you can always get better.”

Clinicians are in the best position to identify waste, he says. “They’re doing a lot of good work. But I would say to board members and physician leaders that the pursuit of perfection is your duty. Your moral duty. And you’ve got to increase the intensity of your effort.”

Zero Harm

“ ‘The pursuit of perfection!’ ” exclaims Terry Platchek, MD, associate chief quality officer and vice president for performance improvement and patient experience at Stanford Children’s Health, in Palo Alto, California. “I love this concept. As a goal, it’s great. Are we ever going to hit it? No. But it’s the ethereal notion of pursuing perfection that makes you better.”

Five years ago, reports Platchek, Lucile Packard Children’s Hospital at Stanford, where he’s associate medical director, was recording six to 10 serious safety events — infections, pressure injuries, close calls — a month. Last year, over the course of 12 months, the total shrank to eight.

“We can say gleefully that we seem to be doing 10 times better,” he observes. “It’s heart-warming. We’re combatting entropy. Pursuing perfection is a kind of magic we have to offer.”

And yet, he quickly adds, “every advancement means more work. Every problem solved creates new challenges. Hundreds of people are devoting thousands of hours to building more safeguards into the system. We as humans have a built-in error line, so the key concept has to be error-proofing.”

In its role as examiner of hospitals to judge their worthiness for accreditation — based on satisfactory performance according to a wide array of measurements — the Chicago-based Joint Commission might be said to be engaged in the pursuit of imperfection.

And, indeed, although it awards passing or failing grades to hospitals, The Joint Commission recently has expanded the scope of its services to include free software suites, education events, publications, training and advisory assistance designed to help hospitals work toward an overarching new ideal: “zero harm.”

Under the rubric of “Leading the Way to Zero,” the initiative aims at nothing short of “zero complications of care, zero falls, zero infections, zero missed opportunities for providing effective care, zero overuse and even zero lost revenue. In other words, zero harm of any kind.”

“The concept is challenging,” says Ana Pujols McKee, MD, The Joint Commission executive vice president and chief medical officer. “And it’s definitely interesting to convince health care leadership that we can actually achieve zero harm.”

Too often, she suggests, “the quality team makes a decision to reduce certain hospital-acquired conditions, but then, where we make our mistake, we don’t talk about reducing them completely. We celebrate small declines in events. Although we know it may take a long time, we need to aim for zero harm. And that means that leadership must create a culture in which individuals can speak up because they trust they won’t be reprimanded for raising issues, then gathering data on near misses, hazardous conditions, sentinel events … and then using that data in a robust process driven not by decrement but by zero.”

Hospital systems may proclaim to the world that they’re constantly striving for excellence. But, notes McKee, “excellence isn’t quantifiable. Zero is.”

‘Walking the Gemba,’ and More

In 2001, intrigued by the widely heralded operating principles and practices of the world’s leading automobile manufacturer (already being emulated by a Seattle, Washington, neighbor, the Boeing Co.), Virginia Mason Medical Center chairman and CEO Gary Kaplan, MD, took his senior leadership team to Japan for a first-hand, in-depth education in the uniquely efficient Toyota Production System.

Eighteen years later, delegations from all departments at the 336-bed, 450-physician integrated health system still visit the automaker’s headquarters each June, still led by Kaplan. There, they receive a two-week refresher course in a methodology that’s become “a culture change built in at all levels of the organization,” says Sarah Patterson, executive director of Virginia Mason Institute. “It’s based on always asking the question, ‘How can we get better?’ ”

Every new hire, from housekeeper to physician leader, receives training in quality-improvement techniques. Many of the ideas are encapsulated in a Lean management vocabulary of “maybe 15” Japanese words — “walking the gemba,” or evaluating a process by watching it being done; drawing up flow charts, conducting root cause analyses and applying other continuous quality improvement techniques ceaselessly to find muda, or waste; equipping technology and empowering people at every level, without fear of repercussions, to interrupt questionable processes before harm results — a fundamental concept called jidoka.

“Based on our experience, those words have [acquired] universal meaning,” says Patterson, who has trained hospital physicians and staff in about 20 countries in the nuances of what is now known as the Virginia Mason Production System. “We can talk with people from the Boeing Co., for example, and everyone knows what we’re talking about. Some organizations don’t want to use the terms. We tell them, ‘OK. That’s not going to be your biggest problem.’ ”

“The power I see in it,” observes pediatrician Donna Smith, MD, executive medical director of Virginia Mason Clinics, “is that whether you’re parking cars or transporting patients or trying to get your colleagues to embrace a new diabetes registry tool, we’re all speaking a common language — a language of improvement.

“Physicians in general are risk-averse,” she observes. “We want things to be defect-free. Here everyone has the courage to identify things they see that are less than perfect because we have the confidence that we can get them closer to perfection.”

Adds Patterson, “It’s kind of like a muscle we’ve developed.”

Another of Virginia Mason’s innovative neighbors, Amazon, often is touted as being on the verge of “disrupting health care.” That idea incenses Patterson. “Why should we be waiting for Amazon?” she asks. “If you live in a mental model that you can’t do something, you won’t even try. Our organizations need to be always exploring and assessing how to be better … what’s it going to take, how are we going to do our work, to get to perfection? The onus is on health care to disrupt itself.”

— D.O.W.

Seeking perfection is part of the mantra at AAPL, where the acronym “CRISP” has taken root. Short for “continuous renewal by inspiring and seeking perfection,” the slogan was added to a conference room wall in recent years.

Pursuing perfection is a good thing, but keep your efforts in check through work-life balance. Experts say it’s important for physician leaders to remember they’re only human.