The Pursuing Perfection initiative was an eight-year demonstration program (2001 through 2008) funded by the Robert Wood Johnson Foundation (RWJF) in the US. With technical assistance from the Institute for Healthcare Improvement (IHI), the goal was nothing less than “perfection,” showing that health care organizations could improve not just one or two aspects of care, in one clinic, unit, or department, but demonstrate that high levels of performance improvement could be a way of life for health care providers, all the time, in all dimensions of quality, throughout an entire organization or system of care. Thirteen health care organizations from the US and Europe designed, tested, and implemented changes in strategy, structure, and key processes, supported by IHI faculty and with frequent contact with each other in a collaborative learning model.
Pursuing Perfection Goals
The Pursuing Perfection initiative challenged hospitals and physician organizations to improve patient outcomes dramatically by “pursuing perfection” in all major care processes. Pursuing perfection meant striving to:
- Deliver all indicated services at the right time;
- Avoid services that are not helpful to the patient or reasonably cost effective;
- Avoid safety hazards and errors that harm patients and employees; and
- Respect patients’ unique needs and preferences.
As noted in the Robert Wood Johnson Foundation Request for Proposals, the Pursuing Perfection initiative aimed to “show that system-wide quality improvement efforts are feasible and, through such efforts, set new benchmarks for health care quality and safety.” IHI and RWJF staff determined that the best way to raise the bar in health care would be to accomplish what Toyota did in automobile manufacturing: show performance improvement that far exceeded anything seen before. If such levels of improvement could be demonstrated among a group of healthcare providers—that is, very low levels of defects and errors, virtually 100 percent adherence to the highest standards of care, and high levels of satisfaction among patients and families—then confidence in and ambition for new levels of improvement would become much higher as a result. The initiative would not only raise expectations among providers, payers, and consumers for higher quality care; it could also demonstrate how to attain this level of achievement.
Key Phases of Work
Pursuing Perfection began with a grantee selection process and included four phases:
Phase I: Site Selection
Applications from 226 health care organizations were reviewed by a 14-member National Advisory Committee; ultimately, 12 organizations were selected for Phase I planning grants.
The selection criteria included:
- High levels of senior leader engagement in quality of care;
- A track record of improvement in care; and
- A feasible but ambitious plan for improving both clinical processes and the infrastructure in the organization.
Phase I: Planning
The grantees then designed and initiated tactical and business plans to pursue perfection. The organizations used as their guide the landmark Institute of Medicine report, Crossing the Quality Chasm. The initial 12 RWJF grantees, joined by the first international (self-funded) participant, Jönköping County Council in Sweden, created their plans for implementing the Pursuing Perfection program in their organizations. The RWJF National Advisory Committee, following a rigorous process, selected seven US organizations from the 12 original grantees to receive Phase II implementation grants of up to $1.9 million each over two years.
Phase II: Implementation
The grantee organizations executed their plans to pursue perfect care. Each organization committed to working on at least seven specific improvement projects that together would help to reach the organization’s goals, while leaders developed strategy and structural changes to support the improvement.
It became clear that the Pursuing Perfection participants (grantees, IHI staff, and RWJF staff) had to create new approaches to achieve ambitious levels of improvement.
As the National Program Office (NPO), IHI was charged with providing technical assistance and direction for Pursuing Perfection. To maximize the learning from all the participants, IHI established a series of opportunities to gather and share information. Face-to-face meetings that gathered all grantee organizations occurred three times a year. By June 2002, the number of organizations participating in Pursuing Perfection had grown to 13; the 7 US organizations awarded Phase II implementation grants from RWJF and 6 (self-funded) international sites: 4 National Health Service (NHS) local health communities in England (North and East Devon, Central Norfolk, Lambeth and Southwark, and Bradford), sponsored by the NHS Modernisation Agency; Reinier de Graaf Group from Delft in the Netherlands; and Jönköping County Council in Sweden, which participated in the first phase of the initiative.
Phase III: Focus on Ambulatory Care
RWJF provided support for the grantees to focus their efforts on improving care across hospitals and beyond hospital boundaries. The goal was to add to the efforts already underway to improve inpatient care with stronger interventions to raise effectiveness and coordination of care for patients both before and after their hospital stays. RWJF grantees each received $150,000 per year for two years to enhance their programs that would bolster care across the continuum. Research and development of innovative solutions to challenges identified during the Pursuing Perfection initiative continued as well. Dissemination accelerated as more learning about how an organization “pursues perfection” became available. A series of articles in Modern Healthcare described the challenges and leadership issues in the initiative. [Berwick D, Kabcenell A, Nolan T. No Toyota yet, but a start
. Modern Healthcare. 2005;35(5):18-19.]
Phase IV: Summarize and Disseminate Key Learning
The grantees and IHI worked to consolidate and package the lessons from the Pursuing Perfection initiative. By this time, the grantees were self-funding all of their efforts to pursue perfection and had been engaged in dissemination for at least two years. They were frequent presenters at regional and national meetings, and two grantee organizations established “sharing days” for visitors to manage the number of inquiries they received.
In 2006, two Pursuing Perfection organizations, Hackensack University Medical Center in New Jersey and Whatcom County in Washington, were featured in the PBS series, Remaking American Medicine
, for their work in Pursuing Perfection. [PBS Television. Remaking American Medicine
. “Program 2: First, Do No Harm” and “Program 3: The Stealth Epidemic.” Crosskeys Media; 2006.]
Pursuing Perfection was not only an ambitious demonstration project, but also an exercise in progressive learning. Through multiple cycles of design, testing, and learning, the grantees and other participantsled IHI to a new view of improvement: achieving the highest levels of performance for patients and organizations, across all major care processes, requires new ways of working.
All participating organizations were able to demonstrate substantial improvement in at least one area of performance.
Equally, the Pursuing Pefection participants learned that two factors are critical to achieving perfection-level performance in health care: 1) substantial changes in the leadership’s approach to quality; and 2) a steady stream of innovative solutions to persistent challenges such as reducing mortality, harm, and disparities.
Even though substantial improvements in structure and processes led to better patient experience, organizations participating in Pursuing Perfection could not demonstrate reductions in cost of care and improvements in the health of the community.
A different level of innovation is needed to address cost of care and population health.
The Pursing Perfection initiative was an incubator for new approaches to leadership and innovation in health care. With these new approaches, we learned that substantial, sustainable, and replicable improvement in quality is possible in health care organizations. However, for the health system to improve, high quality in health care organizations must, in all likelihood, be accompanied by innovations in the organization of services and care delivery across the continuum of patient care.