Archive for April, 2012

Kaiser Permanente nurse reassembles Bay Area history in her mosaic art

posted on April 25, 2012

By Laura Thomas
Heritage correspondent

Mosaic artist Tina Amidon is a long-time Kaiser Permanente nurse who works at Oakland Medical Center in Oakland, California. Photo by Ginny McPartland

Most of us who grew up in the Bay Area were affected in some fashion by Henry Kaiser’s legacy: our parents or grandparents came here to work in his wartime shipyards, or we were influenced by the growth and change the massive migration brought. Untold numbers of us received medical care in the health plan that bloomed in the wake of it all.

Oakland Kaiser Permanente medical-surgical nurse and artist Tina Amidon is a product of the Bay Area and draws inspiration for her art from its diverse and dynamic culture and history. Her childhood in North Berkeley was influenced by artistic and outdoors-loving parents. That influence drew her to a nursing career that allowed her the freedom to pursue those pleasures while nurturing the resilience and intuitive powers she uses to create her art.

Recently she found herself immersed in a particular aspect of Richmond history that ties back to Henry Kaiser’s shipyards and Bay Area culture.

Mosaic loveseat tells Richmond’s story

Her years of working in mosaics, producing large sculptural installations, culminated in October with the public unveiling of a commission for the Richmond Museum of History. From ceramic shards she collected along the shoreline that had been dumped by TEPCO, an El Cerrito dinnerware factory, she built a large diner coffee cup as a tribute to the East Bay’s working class tradition.

Fashioned as a love seat, the cup replicates one of the many styles produced by TEPCO in one of its more popular colors, Sunglow. Along with dozens of broken bits from cups and plates used at various eateries and clubs, the chair features photos of TEPCO workers at the old plant, framed by snaps from discarded pottery molds Amidon also found on the shore; and dinner plates from the Red Oak Victory, the Kaiser-built ship converted to a museum and docked at the former Richmond Shipyard No. 3.

Tina Amidon takes a seat in her mosaic coffee mug in the courtyard of the Richmond Museum of History. Photo by Fina Lloyd.

To Amidon, it forms a quilted narrative of the city, the shipyards and the lives of workers who enjoyed their time off in “the local restaurants and cafes where they spent their hand-earned money after work,” she said.

“This piece honors the men and women who not only worked at the TEPCO factory but built the ships and got their health care at Kaiser Permanente… They sipped their coffee at diners all over the Bay Area and at places like Trader Vic’s and Tad’s Steakhouse.”

And so did the rest of us who were around in the past five decades.

Sandi Genser-Maack and husband Lynn Maack, of Richmond, are TEPCO china collectors and can cite more spots that used Tepco: Mel’s Drive-In, Doggy Diner, Rod’s Hickory Pit, the old Villa De La Paix in Oakland; the Milk Farm on I-80 near Dixon, The Broiler in Sacramento, the Lau Yee Chee Restaurant in Honolulu, Louie’s Club in El Cerrito and the Cerrito City Club. Mama’s Royal Café in Albany still does and there are probably others.

Hundreds of commercial and fraternal establishments ordered dishes with customized logos in a selection of TEPCO colors and designs. The old West was a major theme for many eating places in the mid-20th century and the U.S. Navy was a big customer, according to Genser-Maack. During World War II, she said, “all the Liberty and Victory ships that went to sea left with TEPCO.”

The Technical Porcelain and China Ware Co. – TEPCO’s official name – was founded by Italian immigrant John Pagliero and run by the family from 1918 to 1967. It was the largest dinnerware factory in the West and El Cerrito’s largest business to date.

Trash turned into treasure

Throughout the years, imperfect pieces were unceremoniously dumped, like much garbage at the time, along the bay shoreline where Amidon discovered them a decade ago while walking her dog near Point Isabel. It became her favorite collection spot for mosaic pieces, but it wasn’t until she attended a 2007 exhibition of the Maack collection that she saw her first intact TEPCO plate. She was surprised when she learned about the factory and its place in local history.

“I was able to piece together the whole story,” she said. Literally.

Fascinated by how cast-off items can create a narrative, Amidon says everything she creates tells some sort of story. A 2008 piece, “Allegorical Reliquary,” is a 12-foot-high, 8-by-10 foot roofless room that resembles an abandoned Irish chapel. It resides at Annie’s Annuals in Richmond where customers can amble through it as they shop for flower seedlings. The interior, which has water flowing down the walls inspired by the weeping walls of Zion National Park, features a lively pictorial of mosaics from found objects to tell simply of the joys and struggle of everyday life.

Nursing feeds artistic instinct

During her 22 years as a Kaiser Permanente nurse, Amidon has spent a lot of time listening, and what she’s heard has provided the fodder for the metaphorical tales told in her pieces. Currently she works part time in both Peri-op, giving pre-surgery patients vital instructions, and in the Ambulatory Surgery Unit, where she preps them on the day they arrive for the operation.

“There are all these stories you encounter as a health care person,” she said. “We see a lot of life that other people don’t see.”

Amidon grew up going to art fairs with her mother, a rakú clay artist, and spending a lot of time outdoors (her father was an economist for the U.S. Forest Service). “I would make little clay animals and sell them and that’s how I earned my play money. My mom worked very hard to prepare for all the fairs and I got an early look at the art life.”

In Berkeley High School, she started respiratory therapy training but later realized becoming a nurse would give her both a living and the autonomy to travel for the art education she sought. Over the years the quest for art knowledge has taken her to international museums and sights that inspire her imagery. Before focusing on mosaics in the early 1990s, Amidon worked on drawings and watercolors, lithographs, photography and making floor cloths.

Ideas come from everywhere

“I have tons of ideas. I take classes and figure out how to do things. That how my art always is. I just do it,” she says.

Amidon also relies on the expertise and support of her husband Jim, a mechanical technician at Lawrence Berkeley Laboratory. Married almost 30 years, the couple traveled around the world some 20 years ago and continue to travel, camp, and explore the outdoors. They are known for their travelogue slide presentations given at REI in Berkeley over the years.

Amidon’s first show in 1995 featured wall pieces made from broken china, called “Grandma’s Dishes.” She has since created larger work and has exhibited nationally. The TEPCO chair has been accepted into the Mosaic Arts International 2012, a juried show of the Society of American Mosaic Artists in Kentucky.

Her 2005 sculpture “Passion,” a stylized chair with a heart-shaped back, depicts all forms of strong feeling and is on view at the Stained Glass Garden on Fourth Street in Berkeley. Two wall pieces: “Don’t Smoke in the Garden,” an ashtray the shape of a flower, and “Live Long and Prosper,” a couple sitting inside a hand imitating the split hand sign from Star Trek, are at Snapshot Mosaics on LaSalle Avenue in Oakland.

Bringing art to the people

Not satisfied merely with creating art, Amidon said she is “always trying to draw an audience” and wants to involve more people, particularly the youth in Richmond, where she lives. Amidon enlisted the help of modern dance teacher Jacqueline Burgess and her class at El Cerrito High to choreograph performances that were big hits at both the unveilings of her reliquary (a container for relics) piece and the TEPCO chair.

With Arty Cordisco, the owner of Douglas and Sturgess, an art supply store in Richmond, she is working on a community art space and sculpture garden. Her goal is to pull the large numbers of artists who live in Richmond into a “Bohemian art network” of like-minded folks who can help energize the creative spirit in town.

Amidon encourages everyone to visit her coffee cup in the courtyard of the charming and informative Richmond Museum of History at 400 Nevin Ave. just down the street from the Kaiser Permanente Richmond Medical Center.

Medical Center employees and patients really have no excuse not to pay a visit, she says. Housed in the former Carnegie Library, the museum “is a gorgeous building in itself. You can see the history of Richmond from the native American Indians all the way to farm lands to the Kaiser shipyards,” she said.

“You just go out the back door (of the medical center). It’s two blocks…there’s a park. It’s a great place to bring your bag lunch and have a picnic. You can have your sandwich in my chair. I don’t care.”

YouTube film by Fina Lloyd, Heritage associate

 

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Southern California pediatrician’s career parallels KP’s quest for best

posted on April 18, 2012

By Ginny McPartland
Heritage writer

Last in a series

Sam Sapin, MD, Southern California Permanente Medical Group quality pioneer

The story of Kaiser Permanente in Southern California could not be told better than through the life and career of Sam Sapin, a pediatric cardiologist who joined the medical group in Los Angeles in 1955. Sapin, a New York City transplant with a slight accent reminiscent of his roots, could have had a lucrative career taking care of wealthy patients in his native city. He had a thriving practice on Park Avenue before choosing to migrate to California.

He was lured to Los Angeles after hearing from friends about an innovative, albeit fledgling, group of doctors with a philosophy quite different from his fee-for-service colleagues in New York. Rendering proper and compassionate care to patients without having to consider their ability to pay sounded good to Sapin. So good, in fact, that after one brief visit to the West Coast, he and his wife, Jean, with their two small children, picked up and moved.

In the course of six decades associated with KP, Sapin has seen unimaginable changes, played many roles and helped to nurture the health plan’s phenomenal growth in membership, reputation, and influence in Southern California and in all its regions.

He’s had his hand in establishing and expanding programs in physician and patient education and research; he’s been influential in the creation and refining of quality assessment and improvement systems; and he’s been a trailblazer in KP efforts to ensure appropriate use of medical technology.

LA Center for Medical Education honors Sapin

Sapin received an Excellence in Medical Education Award in 2011 from the Thomas F. Godfrey Center for Medical Education. He was honored for his lifetime achievements, especially in promoting physician education.1  In presenting the award, retired director of the center and fellow pediatrician KP Rudy Brody said: “Over the years no one has done more for Kaiser Permanente to advance medical education, research and quality than Sam.

“He was co-founder in 1955 and a long-standing member of the Southern California Permanente Medical Group’s (SCPMG) Pediatric Symposium Committee (which celebrated its 50th symposium in 2008). Most importantly, Sam was a member of the Center for Medical Education’s Advisory Committee (1999 to present) that guided the center through its initial years.”

These accomplishments are really just frosting on the cake for Sapin whose main career focus has been to take care of newborns and older children with heart problems. His decades-long efforts in this realm have entailed finding groundbreaking ways to repair congenital problems so his often tiny patients could live healthier and sometimes completely normal lives.

In 1981, Sapin was the KP Southern California medical group's director of Research and Education.

As KP physicians have always been encouraged to do, Sapin quickly associated himself with academia and conducted and published research throughout his career, as recently as 2005.

“Shortly after I joined the group I applied for a teaching appointment at Children’s Hospital, just across the street, but I was never accepted, nor rejected, because I was one of those ‘Kaiser’ doctors,” Sapin said recently. “I then drove across town to UCLA, where I was welcomed, became an assistant professor of pediatrics in the Division of Cardiology, and eventually, a clinical professor.

Setting up pediatric cardiac ‘cath’ lab

“I was able to take our pediatric patients to UCLA, perform cardiac catheterizations, and have their cardiac surgery done there. In 1957, Pete Mahrer, Mt. Sinai trained (as Sapin was), joined our group.The two of us set up a small cath (cardiac catheterization) lab at Sunset (KP Los Angeles Medical Center). The equipment was kept in a closet and rolled out into an X-ray room when available.

“We put on our red glasses half-hour before the procedure, to be able to see the fluoroscope in the dark. Pete helped me with the pediatric cases, and I helped him with the adults,” he said. In 1960, a diagnostic cardiac catheterization laboratory for pediatric and adult patients was opened at Panorama City, and Sapin served as director until 1982.

Sapin took on administrative duties when he became the chief of pediatrics at Panorama City in 1959. But he didn’t give up his practice, a decision he never regretted. “Fortunately, for me, I was able to practice until I was fully retired in 2000.”

As chief of pediatrics, Sapin founded the first Kaiser Permanente nurse practitioner program in 1964 and at one point oversaw the training of nurse practitioners. He held the chief position until 1972 when SCPMG Medical Director T. Hart Baker appointed him regional director of the Department of Education and Research, a department created to manage the growing education and research programs funded by the Community Services Fund.

In accepting his lifetime achievement award last year, Sapin recalled: “Seeing patients was very gratifying. On the other hand, my administrative career could sometimes be frustrating. Physicians, who’ve been trained to be problem-solvers and independent operators, can be resistant to change.

“Let me read to you, from a brief memo, which Dr. T. Hart Baker, our medical director at the time, sent out to doctors in May 1972:

“ ‘Dr. Sam Sapin has been appointed director of Research and Education. . . The location of his office and his telephone number will be forwarded to you as soon as a suitable location is found.’

“What I’d like to read to you now is the comment of some anonymous person – presumably a physician – who sent the memo back to me with the following suggestion scribbled on the back of it, in red ink, about a suitable location for my office, it read: ‘On Edgemont, behind garage at 1226 apartment house – go thru back yard, but beware of German Shepherd dog. (Go) up to second story – above chicken coops – and past the old EKG labs.

“Turn left, then right, knock twice and say Marshal. If a short fellow scratching his cheeks answers, turn back, you’re in Fontana! P.S. Dress at this office is casual – jeans and old shirt – since only orange crates and dirty Zolotone boxes are available for desks. Boots are a must, until the exterminators are through. Bring your own Xerox machine, since our last one fell through the loose floorboard. Also, a cheerleader’s megaphone will come in handy for long distance calls.”

Growth of research and education spawns new department

In 1982, Sapin was appointed SCPMG's associate medical director of Clinical Services.

In 1982, newly appointed SCPMG Medical Director Frank Murray founded another new department – the Department of Clinical Services – which subsumed Sapin’s responsibilities concerning research, education and quality. Murray appointed Sapin associate medical director of Clinical Services, which soon included divisions of research, staff training and medical manpower, quality of care, quality of service and appropriate use of technology.

In 1983, Sapin beefed up KP Southern California’s preventive medicine program by requiring each medical center to offer a core health education curriculum addressing chronic conditions and healthy lifestyle issues. Also as Clinical Services leader, Sapin formalized the Inter-Area Chiefs of Service Groups and required chiefs in all specialties to convene four to six times a year. “I thought this structure was essential to assure the delivery of a comparable quality of care throughout the region.”

By 1990, Sapin had served on the SCPMG board of directors for 16 years, as an elected representative from 1957 to 1966 and as a regional associate medical director from 1982 to 1990. He had won the respect of his physician colleagues and the adoration of his patients. In his last years before retirement from the medical group administration, Sapin had several invitations to size up his career and the changes he’d seen. One such opportunity was to speak before the annual meeting of the American Group Practice Association in Minneapolis in 1989.

What makes a successful prepaid group practice?

Rather than speaking just from his perspective, Sapin surveyed his SCPMG colleagues and presented the results in his talk titled “Managed Care – What Works in Groups.”

The survey identified six KP success factors: 1) integrated care design with doctors making medical decisions and KP owning its own hospitals; 2) people with a social purpose and ethics, commitment to high quality and peer review; 3) innovation, long-term planning, nonprofit financing plan, comprehensive care and affordable rates.

Sapin’s list continues: 4) ability to control costs due to ownership of facilities, purchasing power and physician extenders (nurse practitioners, etc.); 5) support from labor, business, academia and government; 6) reputation as a strong organization that is always there to provide care for significant illness. 3

Sapin, a tireless KP defender and passionate believer, summed it all up for his audience: “The right people with a good idea at the right time.”

In 1992 when health care reform was hugely topical and Sapin was retired and consulting for Clinical Services, KP quality leader Sharon Conrow asked him to draft what he thought Kaiser Permanente’s reform position should be. Sapin didn’t hesitate.

“I said, one, I think it should be a single-payer system . . . eliminating the fee-for-service idea. That it would be essentially the model that we have now, but with (ways to address) some of the things we had problems with. For example, when it comes to new technology, what should we invest in?” Sapin recounted recently.

“Now (2012), my recommendation for reform is to duplicate the Kaiser Permanente model. That’s what I’ve been saying. The more I’ve been looking and thinking about this, and all these intrinsic, built-in things that make us have to provide better care based on all the evidence, and so on, (the best structure for effective reform) is the model that we’ve built.”

KP sticks to original HMO model

Kaiser Permanente is the one and only health maintenance organization (HMO), the only managed care organization that fits the original and the current HMO definition, Sapin says. As conceived in 1971 by Paul M. Ellwood, Jr., famed health policy expert, an HMO consists of a multi-specialty group practice whose doctors contract with a nonprofit health plan to take care of patients on a prepaid basis.

Ellwood, who has influenced national health policy over the decades, is frustrated by the lack of progress on the health reform front. He said he originally intended HMOs to be nonprofit entities and to include structure to ensure accountability for quality of care as well as to contain costs, the main objective in the early 1970s as well as today.

“What went wrong?” Ellwood asks rhetorically in his 2011 oral history. His answer: “Political expediency in the initial plan designed to promote HMO growth led to the inclusion of three mistakes: for-profit plans, independent practice associations, and the failure to include outcome accountability.”

Ellwood’s sad assessment gives credence to Sapin’s argument that KP stands out as the model. Ellwood says of Kaiser Permanente and its pioneering physician Sidney Garfield: “Sid Garfield’s plan is 80 years old but it is still the gold standard.” 4

 

1 The Center for Medical Education was founded at the KP Los Angeles Medical Center in October 1999. The center offers continuing education, residency and fellowship programs and rotations for residents and fellows from nearby medical schools. Its advisory committee draws members from the community as well as SCPMG.

2 Sapin earned his MD from the New York University College of Medicine and completed a rotating internship at Mt. Sinai Hospital and his residency in internal medicine at the U.S. Veterans’ Hospital, both New York institutions. He took his internship in pediatrics at Bellevue Hospital in New York and his residency in pediatric cardiology at Mt. Sinai Hospital in New York City.

3 “Managed Care – What works in groups 1989 – A case study of successful HMOs,” Samuel O. Sapin, MD, presented at the Annual Meeting of the American Group Practice Association, Minneapolis, Sept. 15, 1989

4 “Paul M. Ellwood, Jr., MD, In First Person: An Oral History,” American Hospital Association, Center for Hospital and Healthcare Administration History and Health Research & Educational Trust, 2011

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Kaiser Permanente HealthConnect offers power to crack the quality nut

posted on April 11, 2012

By Ginny McPartland
Heritage writer

Kaiser Permanente's first stab at formal quality assessment, low-tech paper and typewriter hospital reviews by first woman hospital administrator Dorothea Daniels in 1962

Seventh in a series
In 1989, Southern California quality guy Sam Sapin, MD, made a prescient plea to KP leadership: invest in information technology to improve quality of care. Having worked on quality issues for decades, Sapin saw the need for a KP database to be shared among all regions.

“This would allow us to compare ourselves to each other,” Sapin told a gathering of KP quality professionals. He continued: “The data must be accurate, otherwise one loses credibility and effectiveness. The data must be timely, not two to three years old, because the environment changes quickly these days. . .We need to develop data that will show the outside world – the public, employers and legislators – how good we are.”

Twenty-two years later, KP is positioned to capture detailed patient data across all KP regions and to analyze it in many different ways to learn what’s working and what isn’t. With an abundance of data, KP can not only record adherence to best clinical practices, but also potentially figure out more precisely how treatment affects outcomes.

Halvorson’s big initiative to improve quality with data

In 2002 when George Halvorson took over Kaiser Permanente as president and CEO, the Care Management Institute was well on its way to performing the essential function of developing and sharing best practices among all KP physicians. But Halvorson, acutely interested and knowledgeable about medical information systems, was not satisfied that KP was on the path to develop a patient data system that would support his vision for quality improvement.

Telling the story of how rich data helps to achieve quality improvement. KP experts contributed to this book edited by Louise Liang, HealthConnect leader. See below*

He brought in Louise Liang, a physician, medical director and quality professional who had worked closely with Total Quality Management expert Donald Berwick at the Institute for Healthcare Improvement (IHI). She led the program-wide monumental task of finding an appropriate vendor, figuring out the best software and driving the implementation of KP HealthConnect, ultimately the data collection and interpretation system that would transform Kaiser Permanente’s ability to assess and improve quality.

In 2005, KP reorganized its quality management structure, creating the KP National Quality Committee (KPNQC), which took the place of the Medical Directors’ Quality Committee. The NPNQC oversees all quality activities for hospitals, outpatient clinics, and outside care for all KP regions.

Value of data to quality measurement

Fully implemented in 2010, KP HealthConnect has the capacity to generate comparable data across all KP regions, thus enabling physicians and other quality analysts to measure and compare quality results from all of KP’s facilities. KP HealthConnect also can use data to perform a much broader range of research to feed the CMI’s search for data to validate and refine Permanente best practices.

KP's current CEO George Halvorson

“Having data is extremely important,” Halvorson told the editors of the NCQA 20th anniversary report. “Whenever you have data you can reach conclusions and you can change process, you can re-engineer, you can make things better. But if you don’t have data, you don’t have any particular direction to go.”

He adds, “There is an evolution from process to outcomes, and measuring the mortality rate for different conditions is a wonderful measurement, sort of the ultimate definition of outcome. Measuring process is good, and a far better thing than not measuring quality at all, but organizations really need to focus on what happens to each person. How many people have failing kidneys is a great measurement.”

NCQA president validates KP success in quality improvement

In her 20-year assessment of NCQA’s success in improving quality of care, President Margaret E. O’Kane concludes: “Our hard work has led to many gratifying and exciting results. In Northern California, for example, Kaiser Permanente has demonstrated that aggressive management of patients with coronary artery disease (CAD) pays off in the most important ways: fewer deaths.

“CAD is the leading cause of death in every other county across the U.S., but for Kaiser (Permanente) patients in Northern California it is second. This confirms that when quality measurement and science meet, patients benefit,” she wrote.

KP’s electronic medical record system also makes it possible for physicians to access a patient’s full medical history anytime in any KP facility.

“You never ever have to make a clinical decision about a patient without information,” Andy Weisenthal, KP pediatrician and quality expert, told Charles Kenney, author of Best Practices: How the new quality movement is transforming medicine.” He adds, “I cannot tell you what that means to me as a doctor.”

Has Kaiser Permanente been successful in demonstrating its high quality of care? The abundance of accolades showered onto the KP medical care program over the past decade speaks for itself.

In the fall of 2011, KP received the highest rating in 11 effectiveness measures – more than any other health plan in the nation – in the 2011 NCQA’s Quality Compass results.

KP also won J.D. Power & Associates first place awards, as well as the prestigious Davies Award for KP HealthConnect, the patient data system.

KP also distinguished itself by garnering Medicare five-star awards in five regions, outstripping other health plans in California, Hawaii, Colorado and parts of the Northwest. Only nine Medicare plans in the country earned five stars for the overall 2012 Medicare star quality rating.

Next time: Sam Sapin: Southern California pediatrician’s career parallels KP’s quest for best quality

To learn more about KP current quality honors:

 http://xnet.kp.org/newscenter/pressreleases/nat/2011/091311himmsdaviesaward.html

http://xnet.kp.org/newscenter/pressreleases/nat/2011/101011ncqacaremeasures.html

http://xnet.kp.org/newscenter/pressreleases/nat/2011/101211medicarestarqualityratings.html

http://xnet.kp.org/newscenter/pressreleases/nat/2011/032311jdpower.html

*Louise Liang’s book is discussed in the Permanente Journal and is available on Amazon.com.

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Richmond shipyard women – Homefront heroines

posted on April 10, 2012

A recent gift to the Heritage Resources archive – a Kaiser Richmond Shipyards photo of 20 female workers, one happy fellow, and a nurse. This acquisition was from Terry Meneze, granddaughter of Mamie Allen (middle row, far right) who came to California from a dustbowl cotton farm in Oaklahoma in 1942 with her four children seeking a better life. [LC]

Names and cities of origin are written on the back, but not linked to any face.Frances Huff, Salem, Illinois – “Slow Poke”; Muriel Kidd, Evanston, Wyoming; Frances Huff, Salem, Illinois – “Slow Poke”; Ina Hallum, Arkansas; Gertrude “Bobby” Fall, California; Helen Brashear, Oklahoma; Donna Lee Tudder, McGee “Cale”; Shirley Marriott, “Dumbo”, Ogden, Utah; Viola Meddo, Oklahoma; Sally Perata; Anita Siehl, San Francisco, California; Myrtle Dedman, Trumann, Arkansas; Wilma Salonish, California, “Prune”,”Mrs. Mike”; Eunice Smith, “Little Smitty Honey,” Wisconsin; Willie Rogers, Louisiana; Mrs. Medley, Arkansas; Christine Cole, McAlester, Oklahoma; Lois Allen, Fargo, North Dakota; Louelle Erikson, Billings, Montana; Lois Stoelting; Mamie Allen.

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How do physicians know they’re doing the right thing?

posted on April 4, 2012

By Ginny McPartland
Heritage writer

Sixth in a series

Kaiser Permanente founding physician Sidney Garfield, circa 1933. Garfield's spirit of innovation and ever-improving health care lives on.

Medical doctors have been plagued for generations with a nagging uncertainty about what treatment is the best for each patient who seeks care.  Without scientific proof of the value of treatment, how was he or she to know for sure the care provided would cure and not harm. Tradition and conventional wisdom had to suffice in the absence of research and hard facts. Little was cut and dried.

As medical science advanced in the 20th Century, more research offered more knowledge. But as technology raced ahead, it seemed to leave more questions than answers in its wake. Is it worth the risk, worth the expense? How can we predict the outcome?

Enter the quality of care watchdogs of the 1970s, 1980s and 1990s. The federal government, employers and consumers were organizing to pressure all health care providers, especially health maintenance organizations, like Kaiser Permanente, to demonstrate high quality.

Kaiser Permanente physicians, who had been exploiting the benefits of practicing in a collaborative and forward-thinking group for 50 years, found themselves at a crossroads. Having grappled with the quality issue already for decades, Permanente physicians took a collective deep breath and again launched into a quest for an effective way to prove KP’s quality of care. This time, they knew they had to take dramatic action.

Quality Agenda gets new energy from medical groups

David Lawrence, MD, KP health plan CEO, a prime mover in the Quality Agenda program launched in 1991. Spectrum photo 1991.

The first comprehensive initiative was unveiled in 1991 – the Quality Agenda – inspired by Donald Berwick, MD, the Total Quality Management (TQM) proselytizer. KP leaders adopted TQM and implemented an aggressive new quality program modeled on its principles. This movement launched a number of programs that emphasized developing and continually updating standards of care in tandem with the National Committee on Quality of Care (NCQA) and other review groups. (See previous blogs posted March 21 and 28.)

But in 1994, Permanente physicians and David Lawrence, CEO, of KP Health Plan and Hospitals, concluded that the 1991 TQM initiative had not done enough to propel KP quality efforts forward.

Sharon Conrow, director of Quality Systems, later explained the rationale in a 1999 Permanente Journal article, co-authored with Rob Formanek, MD, the medical director for The Permanente Federation.

“The Boards’ annual reviews continued through the early 1990s and led to continued improvement of the KP Regions’ quality processes and infrastructure,” she wrote. “However, these efforts neither inspired the rapid improvements necessary to meet growing expectations (of consumers and others) nor led to the improvement needed for compliance with NCQA requirements or HEDIS (Health Plan Employer Data and Information Set).

Quality leaders, looking back on these events from 1999, noted that regional quality efforts had been mainly successful over the years, but that the KP national health plan board of directors and KP physician groups – as a national entity – were ultimately responsible for quality of care and patient safety, and they had to take the helm. In 1996, Lawrence asked the Permanente medical group directors in all the regions to propose a new approach to quality review.

Medical Directors’ Quality Committee established

The medical groups and health plan and hospital officials set the quality scheme in motion by creating the Medical Directors Quality Committee (MDQC) in 1995. To put additional power behind the initiative, the physician groups formed a strong alliance among all the KP medical groups. The alliance was initially called the Permanente Medical Group Interregional Service and was renamed in 1997 to The Permanente Federation (TPF) as it’s called today.

"Quality Initiatives & Outcomes Projects: Firmly Planted: Far Reaching," KP report 1996

In “Quality Initiatives and Outcome Improvement,” an update of the Quality Agenda published in December of 1996, the MDQC and the resultant MDQR (Medical Directors’ Quality Review) were discussed. It was described as a program to “complement and enhance other quality review work processes, such as accreditation by the National Committee for Quality Assurance. The emphasis is on peer-to-peer evaluation and on using the review not just for quality assessment but as a powerful tool for quality improvement across the (KP health) plans.”

Care Management Institute established to develop clinical guidelines

One of the first charges for the new health plan-medical group partnership (Kaiser Permanente Partnership Group, founded July 1997) was to devise a system to standardize physician performance in all KP regions. These common practice guidelines, collectively called Permanente Medicine, had to be based on scientific evidence. To accomplish this, in 1997 the partnership established the Care Management Institute (CMI), which develops clinical guidelines based on the strength of available scientific research.

In 2002, departing CEO David Lawrence, MD, told Managed Care magazine: “We’ve agreed that we need to review the scientific evidence and medical evidence in a systematic way and then disseminate it through the entire organization. As a result, a doctor in Atlanta uses the same science and set of evidence and practices with the same understanding of what’s best for the patient as a doctor in Hawaii uses.”

Jay Crosson, MD, president of The Permanente Federation its first 10 years

In a 2007 article, Jay Crosson, MD, president of The Permanente Federation for its first ten years, draws a parallel between KP physician founder Sidney Garfield’s insistence on constant change and innovation and the quality improvement work the MDQC had done since 1997. “Out of the (national agreement) came not only The Permanente Federation but the Care Management Institute – a jointly managed entity with a mandate to pursue the kind of program-wide quality improvements that Dr. Sidney Garfield envisioned. . .”

Next time: KP HealthConnect data offers potential to crack the quality nut

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