By Ginny McPartland
When we talk about quality of care today, the name “Jim Vohs” inevitably comes up. That’s because many Kaiser Permanente (KP) people have heard of the annual James A.Vohs Award for Quality. It’s a great honor to receive the Vohs award, and every year since 1997 people across the program have pulled out all stops to garner the coveted distinction for quality improvement projects. But fewer people know the story of James A. Vohs, the man behind the name, and why he is associated with quality assurance.
Jim Vohs was an early health plan leader, a champion of prepaid, group medical practice, a believer in strong partnerships between health plans and the medical groups, and an adamant advocate for Kaiser Foundation Health Plan and Hospitals as nonprofit institutions that provide quality, affordable health care.
Right out of Berkeley High School in 1946, Vohs first worked as a “mail boy” for a Kaiser Industries unit called Kaiser Services, where his mother worked as a bookkeeper. After his graduation from UC Berkeley in 1952, he rejoined Kaiser Services, which provided administrative support for the various Kaiser industrial companies, like Kaiser Steel, Kaiser Aluminum and Kaiser Engineers.
With his career blossoming, he shocked his Kaiser Services colleagues by choosing to switch to the nonprofit Kaiser Foundation Health Plan and Hospitals in 1957 because he believed in its principles. It was a good choice. During a 50-plus year career, he rose to become President and CEO as well as the first chairman of Foundation Health Plans and Hospitals boards of directors who was not a Kaiser family member, succeeding Edgar F. Kaiser, Henry J. Kaiser’s son.
Quality a big priority
Quality of care was an issue early on in the life of the Kaiser Permanente Medical Care Program. Detractors of prepaid, group practice were quite happy to spread rumors about how Kaiser Permanente doctors were not qualified or competent and that their patients were “captives” of no choice.
Vohs was very much aware that these attacks contributed to a “poor reputation,” however wrong, in KP’s early days. Even the prevailing attitude at Kaiser Services was that the medical care program was an “embarrassment.”
Meanwhile, Kaiser Permanente was early and quick in its efforts to show the skeptical world evidence of its excellent care. Early physicians published research that showcased their innovative treatment, sponsored medical symposiums, aligned themselves with academic medicine, and kept their heads down when the insults were hurled.
Reputation aside, Jim Vohs had faith in the high caliber of Permanente physicians, and he bravely faced critics who implied Permanente cut corners in medical treatment. “It is quite clear to me that the economic incentive . . . for the program and the participating physicians —who by and large spend their careers (with Permanente) — is to resolve medical problems as promptly and completely as possible,” Vohs told an interviewer in 1983.
Documenting quality of care
Today’s medical quality movement got its start with the creation of the Joint Commission on the Accreditation of Hospitals in 1952. The federal government started requiring quality data following the adoption of Medicare for the retired and Medicaid for the poor in 1965. The American Hospital Association published its Quality Assurance for Medical Care in the Hospital in 1972. The HMO (Health Maintenance Organization) act of 1973 required each federally qualified HMO to have an internal quality assurance program.
In 1974, Kaiser Permanente physicians from all regions started meeting regularly to discuss quality related issues, and Vohs established a department of quality and a board of directors committee on quality assurance. The committee, including Vohs, made site visits to each of the regions several times a year.
In 1979, Drs. Leonard Rubin and Sam Sapin served on an advisory committee that set up the National Committee for Quality Assurance (NCQA), which sets standards for HMOs. The Permanente physicians were successful in getting the committee to adopt a problem-focused approach to quality assessment, which Rubin had developed and tested starting in 1967.
By 1983, Kaiser Permanente was getting good reviews. Dr. Sapin reports: “Almost without exception, published reports comparing health care delivery by Kaiser Permanente physicians to others have shown us to be better than or at least equal to others.”
Vohs is proud of having the quality award as part of his legacy: “It’s so important for Kaiser Permanente. The regions are competing for the award; they are supporting programs in quality because they want to win that award.”
Vohs a key player in KP milestones
Throughout the years, Vohs played a key role in many of the milestones of Kaiser Permanente’s history. Each chapter helped to make Kaiser Permanente stronger and more capable of providing high quality care.
• Passing of the Federal Employees Benefits Act in 1959. This legislation was heavily influenced by Kaiser Permanente leaders who urged Congress to include a choice of fee-for-service and prepaid medical plans. Kaiser Permanente gained many members as a result.
• Passing of the HMO Act of 1973. Kaiser Permanente leaders also heavily influenced this legislation. They worked with Health, Education and Welfare Agency officials to develop a proposal for a per-person or capitation method of Medicare reimbursement for health maintenance organizations (HMOs), which became part of the act.
• Formalizing Equal Employment Opportunities (EEO) and Affirmative Action practices in the 1960s and 1970s. Opening a Kaiser Permanente EEO conference in 1976, Vohs reaffirmed Kaiser Permanente’s commitment to the employment of minorities and women. He reported an increase of minority and women employees from 4,600 in March 1974 to 5,084 a year later, almost one third of the total work force at the time. Women held 56 percent of the management or supervisory positions in 1975, up 2 percent from 1975; minorities held 14 percent of the top jobs in 1975, compared to 13 percent a year earlier.
Vohs affirmed KP’s historical “one-door, one-class” system of health care dating back to 1945. “Each member is entitled to necessary medical care of the same quality, in the same place, irrespective of income, race, religion or age. Given this policy, it would make little sense if we were to discriminate in our employment practices.”
• Partnership and eventual takeover of the Georgetown Health Plan strategically located in Washington, D.C. This medical care program provided the springboard for the creation of our Mid-Atlantic States region.
• Convening a meeting among health plan and medical group leaders in 1996 to re-confirm the principles of the historic 1955 Tahoe Agreement. The earlier agreement set up the business relationship and clear authorities for the Kaiser Permanente Health Plan and Hospitals leadership and the Southern and Northern California medical groups. Forty years later, the outcomes of “Tahoe II” were the National Partnership Agreement and the creation of the physicians’ Permanente Federation, which represents all regional medical groups in dealings with the health plan leadership.
Kaiser Permanente on a mission
An able administrator, Vohs believed in the health plan: “There was a sense of commitment to a program that was performing social good and demonstrating a way of providing care and financing that was important to the country.”
Vohs firmly dispatched any insinuation that Kaiser Permanente was like for-profit health plans: “Over the years, Kaiser Permanente has been driven by particular values that essentially relate to providing quality medical care to enrolled members for a fixed monthly premium. We don’t conceive of ourselves as a commercial enterprise,” Vohs told John K. Iglehart of Health Affairs in 1983. Quoted in a New York Times article “King of the HMO Mountain” the same year, Vohs added: “There’s a certain missionary zeal in what we’re doing. We think this is a good model for the way in which medical care ought to be organized – so we want to see it spread.”
The Southern California Region’s Proactive Office Encounter (POE), which promotes preventive care, and the California regions’ programs to prevent heart attacks and strokes, were awarded the 2009 Vohs Awards earlier this year. The Fall 2010 issue of the Permanente Journal carries an article about the POE.