The Working Together Consortium Health Care Initiative, a task force assembled under the auspices of the Allegheny Conference on Community Development, expects by January to get signatures on a new "community contract." This contract would commit hospitals and physicians here to making significant quality improvements in the way they do five of the most frequently performed, highest-cost medical treatments.

The contract will also call on participating medical institutions and doctors to eliminate medication errors in hospitals and to eliminate the kinds of preventable infections that patients develop purely as a result of a hospital stay. In addition, the Consortium is devising ways to curb what some business leaders see as duplicative services and facilities that are thought to add to the region’s overall health care costs.

The first draft of the Consortium’s contract will be reviewed Dec. 6 at a meeting of its members.

The specific treatments the group will put under the microscope are caesarian sections; hip replacement surgery; cardiac surgery and clinical management of depression and diabetes. Together those treatments account for $233 million in health care costs in Allegheny County alone.

By launching the effort, the Consortium aims not only to improve treatment here, but to turn Pittsburgh -- currently a laggard in adopting quality or cost initiatives in health care -- into a model for medical reform efforts elsewhere.

The Consortium’s main thrust is to get hospitals and doctors to employ some of the same principles of process engineering that manufacturers use to reduce defects in their products and make their systems more efficient.

The Consortium’s chairman and most visible corporate backer, Alcoa Chairman Paul O’Neill, is widely recognized for implementing these so-called continuous quality improvement practices on the factory floors and in the offices of the world’s biggest aluminum company.

The health care initiative is in line with a national trend that has spurred community and business groups around the country to probe the medical establishment and insurers about the cost and quality of care.

However, unlike some other visible community-led health care initiatives, the Consortium’s efforts will, at least initially, focus exclusively on the quality rather than the pricing of medical treatment.

But just like health reform efforts elsewhere, the Consortium’s plan is likely to face an array of hurdles. Obstacles faced elsewhere have ranged from less than whole-hearted enthusiasm from doctors and hospitals to inadequate support from business leaders.

The obstacles could even be greater here because the Consortium’s effort is among the most ambitious yet mounted, according to two national authorities.

The reason for focusing on quality rather than price competition is that it’s perhaps the only way to ever have real impact on seemingly intractable increases in medical cost, O’Neill said. "If you really want lasting change, you don’t fall back on the old tools."

Tools used by others, including the federal government and managed care insurers have largely been economic ones, ranging from changes in reimbursement methods designed to lessen the amount of time patients spend in hospitals to flat out cuts in doctor’s fees.

But the methods don’t seem to be working and, in O’Neill’s view, may actually be contributing to cost increases. For example, discharging patients too quickly from hospitals can result in costly readmissions.

It’s not that the Consortium is unconcerned about costs. In fact, O’Neill said he believes that well-conceived quality reform programs could cut health care costs by as much as 50 percent.

To understand that, it’s important to know that medical care varies tremendously and that errors are far more frequent than most people imagine.

Just one small example already unearthed in the Consortium’s research on caesarian sections speaks volumes.

Unless there is a medical need for a caesarian, the procedure can pose risks for mothers and babies that they would not face in a natural birth. In addition, they are also significantly more costly.

The number of babies delivered by caesarian section to mothers who wouldn’t seem likely to need one varies greatly in this region -- from 7.9 percent to 18.6 percent, depending on the hospital where the delivery occurs.

The differences are even greater, depending on the obstetrician who performs the delivery.

The Consortium wants doctors around the region to study these so-called "practice variations" and determine why the differences exist. The thinking is that in doing so, doctors will be able to reduce the number of unnecessary caesarians, benefiting patients and lowering costs at the same time.

Similarly, the Consortium found that some 6.3 percent of patients who had total hip replacement surgery in the 12-month period it researched had to be readmitted to the hospital within 30 days. About 14 percent of the patients suffered "complications" of one kind or another.

By collaborating, the Consortium hopes the surgeons can improve those statistics.

"Now it’s incumbent on hospitals and doctors to sit down and look at this data and say ‘What does this mean to us,’" said Dr. Carl Sirio, a UPMC Health System physician who chairs the Consortium’s clinical advisory committee.

Experience elsewhere suggests it can mean a lot.

Medical institutions that have applied "process improvement techniques" have demonstrated that they can achieve quality gains and that those gains do result in lower costs.

Salt Lake City’s Intermountain Health Care System 13 years ago mounted what is now one of the most widely lauded quality improvement programs.

Using its flagship LDS Hospital as a laboratory, it developed 65 protocols for either reducing practice variations among physicians or bringing all physicians into line with certain standards of care that were deemed the best, based on research.

One clear example of its success was reducing the rate of deep wound infections among patients who had surgery by more than half in less than three years, said Dr. Brent James, IHC’s medical research director.

The rate went from 1.8 percent, which was already lower than a national average of about 2.5 percent, to 0.4 percent.

One big contributor: Getting doctors to make sure that patients received antibiotics no later than two hours before surgery.

Overall, the improvements have helped IHC shave annual operating costs by about $30 million, or 2 percent, even though only 3 of the 65 protocols have been adopted throughout its 23-hospital system.

James, in a phone interview, said he believes that the Consortium’s quality initiative is both well conceived and ambitious. If successfully implemented, it would probably rank among the top five institutional and community led reform efforts in the nation, he added.

He said the Consortium has chosen "the right list" of clinical issues because they are "high priority areas with big opportunities" for quality and cost improvement.

The goals of eliminating medication errors and preventable infections in hospitals -- ones the Consortium views as its marquee efforts -- "are the big number one and big number two," he said.

Still, success is hardly assured. Other communities mounting health care reform efforts have met with varying degrees of success and there have been some visible failures.

In Cleveland, a reform effort similar to the Consortium’s collapsed earlier this year when the Cleveland Clinic withdrew from it. According to news accounts, the Clinic’s health system -- whose size and stature make its impact on Cleveland similar to UPMC’s impact on Pittsburgh -- was put off by the costs of participating and by rankings that didn’t always place it at the top. In addition, lulled by tamer inflation in health care costs, some in the business community had lost interest.

Indeed, hospitals and physicians are often reluctant partners in community-led health reform efforts. Some argue that methodologies and comparisons are often unfair, and there is widespread resistance to public scrutiny of their performance.

"It’s very difficult for hospitals and doctors to willingly come along in a process where they’re being evaluated," Sirio said.

The Consortium, however, has tried to avoid some of the pitfalls that have undone reform efforts elsewhere, said its director, Ken Segel.

"We’ve tried to change the basic relationship" between health care purchasers and medical providers.

Among other things, the Consortium is letting health care providers develop the bases for comparison of their performance. In addition, for at least a while, it will keep the comparisons out of public view and focus on improvement rather than criticism.

Because quality improvement programs also entail costs up front, the Consortium is also looking for ways to help fund them.