Posts Tagged ‘Cecil Cutting MD’

Kaiser Permanente’s work to provide affordable pharmaceuticals – since 1943

posted on April 5, 2016

Lincoln Cushing
Heritage writer

 

File #3078A - Pharmacists fill prescriptions, 1940s, Oakland Hospital

Pharmacists fill prescriptions, 1940s, Kaiser Oakland Hospital

Everybody complains about the high cost of pharmaceuticals in the United States.  Medication that is within one’s budget can make the difference between a course of treatment that is successful and one that isn’t. Kaiser Permanente is part of a coalition of health care organizations and other stakeholders determined to make drugs for health more affordable. But few know that our efforts to bring down drug costs began during World War II, when we created our own in-house drug manufacturing capability.

One of our emeritus physicians, Morris Collen, MD, spoke about it in a 1986 oral history transcript:

During the war, since the purchase of medications was very expensive, Dr. Garfield set up Royfield, which is a combination of syllables for Sidney Roy Garfield – Roy and Field. Julian Weiss was our first director of pharmacies. I remember we had an old barn and in it they made most of our medications. I recall that they stamped out the pills for common drugs like Donnatal, and that was our Rx number five. Donnatal, Phenobarbital, and aspirin–we had a formulary, which contained a majority of the common drugs we used. At considerable savings, Royfield stamped out all these pills, made all the cough medicines, and all that sort of stuff.

On October 13, 1943, Permanente Foundation Health Plan physicians Sidney Garfield (general partner) and Cecil Cutting (special partner) formed a limited partnership titled “Royfield & Company” to supply many needed drugs and medications for the hospital, clinics, and first-aid stations operated by the Foundation. To capitalize the partnership, Garfield put up $15,000 and Cutting put up $5,000. Dr. John Smillie’s book about the history of the Permanente Medical Group, Can Physicians Manage the Quality and Costs of Health Care? described the importance of this effort:

…Garfield introduced into the Foundation program a capacity for in-house drug manufacture that would make the future Kaiser-Permanente Health Plan the largest private prescription drug distributor in the United States.

File #3077A Cropped - Julian Weiss at counter of Oakland Hospital pharmacy, 1940s

Pharmacist Julian Weiss at counter of Kaiser Oakland Hospital pharmacy, late 1940s.

Royfield operated out of a secure warehouse not far from the flagship Kaiser Permanente Oakland hospital near 51st Street and Broadway, where trucks could drive inside and securely load these crime-magnet products.

In 1952 Royfield became formally integrated into the health plan as Dapite. The program was highlighted in a TIME magazine article from 1962, “Prepaid Medical Care: Nation’s Biggest Private Plan”:

Dapite, Inc. is a planwide subsidiary which prepackages medicines and supplies them at bargain rates to the hospitals and clinics (whose doctors also agree to use mostly generic-named drugs, cheaper than the trademarked equivalents).

Northern Ireland pharmacist Margaret McClelland worked at Dapite for eight months in 1961, and wrote this account in the United Kingdom publication The Chemist and Druggist:

The Kaiser Foundation Hospital in Vallejo, where Dapite is situated, has a rehabilitation centre at which is operated a specialised technique perfected by Dr. Mead and Miss Knott (chief physiotherapist). Dapite, Inc., has, in the past, employed many disabled people from the Centre as part of its rehabilitation scheme. At the time of writing two such workers, victims of mining accidents, repackage drugs and two polio victims are on the office staff. Products manufactured by Dapite include x-ray solutions, pharmaceutical solutions, lotions, mixtures, ointments, eye preparations and disinfectants. Much of the work comprising repackaging of drugs in smaller quantities.

While I was at Dapite two young assistants carried out the heavier and “bulk” work — for example running alcohol from 40-gallon drums into l-gallon containers. Disinfectants, x-ray solutions, dextrose solutions, were put up similarly.

Orders were mailed in each morning by the various pharmacies or recorded on the telephone. Our day started at 7.30 a.m. when a hospital truck collected the orders and delivered them, providing a reasonably fast service within the 40-mile radius from Vallejo. The trend towards proprietary drugs I found even more marked in California than in Ireland.

Reporter 1964-06

Don Murray, Dapite manager, shows samples of drugs packaged at Dapite to Virginia Young (right) and her assistant, Paula Haug, who handle drug purchasing. Inset: Julian Weiss, purchasing agent and director of pharmacies. KP Reporter June, 1964.

In January 1963, the manufacture and wholesaling of drugs, previously conducted by Dapite, Inc., as a subsidiary of Kaiser Foundation Health Plan, was taken over by the department called Permanente Services, which centralized the competitive bid purchasing of virtually all supplies and equipment for Kaiser Permanente operations in Northern California. The KP Reporter described the transition:

At the same time Permanente Services took over the retail pharmacies at detached Medical Offices which had previously been operated by KF Health Plan. Purpose of these organizational changes, which do not affect the day-to-day functioning of the pharmacies, was to eliminate from the Health Plan structure any enterprise which might be considered commercial. The Dapite Company will be dissolved.

Today, Kaiser Permanente continues its efforts to address the high prices of prescription drugs by participating in public dialogue around the issue, advocating for our members and communities, and thus continuing the work we started in 1943 to reduce the cost of pharmaceuticals.

 

Short link to this article: http://k-p.li/1RWQmsy

 

 

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Physician-nurse team helps Permanente medicine through early days

posted on September 16, 2013
Cecil and Millie Cutting were among the first medical staff of Henry Kaiser and Sidney Garfield, MD, care programs for Grand Coulee and Richmond Shipyard workers in the 1930s and 1940s.
Cecil and Millie Cutting were among the first medical staff of the care programs set up by Henry Kaiser and Sidney Garfield, MD, for Grand Coulee Dam and Richmond Shipyard workers in the 1930s and 1940s. Kaiser Permanente Heritage Resources photo.

By Ginny McPartland, Heritage writer

Cecil and Millie Cutting, a couple that looms large in Kaiser Permanente’s early history, met in Northern California at Stanford University in the early 1930s. He was training to become a physician; she was a registered nurse with a degree from Stanford. They met on the tennis courts and married in 1935.

During her husband’s nonpaid internship, Millie Cutting worked two jobs – for a pediatrician during the day and an ophthalmologist in the evenings – to pay the bills. He was making $300 a month as a resident when Sidney Garfield, MD, contacted him about joining the medical care program for Henry Kaiser’s workers on the Grand Coulee Dam in Washington State.

At Grand Coulee, Millie Cutting exhibited her strength as a staff nurse and as a community volunteer. Probably her most significant contribution was the development of a well-baby clinic in a community church.

Well-baby clinic supported by madams

As a volunteer, she organized the clinic and went door to door soliciting funds for its operation. She had no qualms about knocking on the portals of the town’s brothels.

“The madams were very friendly,” Cecil Cutting told fellow physician John Smillie, author of a history of The Permanente Medical Group. “The community church provided the space and the houses of ill repute the money – a very compatible community.”

The Grand Coulee Dam was completed in 1940, and the medical staff and their families scattered. The Cuttings settled briefly in Seattle where Dr. Cutting set up a surgery practice.

But it wasn’t very long before World War II broke out and Dr. Garfield was called upon again to assemble the medical troops for a program at the Richmond, Calif., Kaiser Shipyards. Cecil Cutting was enlisted as the chief surgeon.

Garfield’s right hand ‘man’ at wartime shipyards

Millie Cutting volunteered to work side by side with Sidney Garfield to get the medical care program up and running and to take charge of any job that needed to be done.

She recruited, interviewed and hired nurses, receptionists, clerks, and even an occasional doctor, to staff the health care program that was set up in a hurry in 1942. She smoothed the way for newcomers and helped them find homes in the impossible wartime housing market.

Thoroughly adaptable Millie drove a supply truck between the Oakland and Richmond hospitals and the first aid stations and served as the purchasing agent for a time.

As she had done at Grand Coulee, Millie set up a well-baby clinic for shipyard workers’ families, and she opened her home in Oakland as a social center for the medical care staff.

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Kaiser Permanente members ‘mobilize’ to manage health care

posted on February 28, 2013

By Ginny McPartland,Heritage writer

Colossus was an early supercomputer that was used by the English to crack Nazi codes during the Second World War. The computer, at Betchley Park, England, is preserved in the National Museum of Computing opened with funds from English Heritage in 2008. Photo by Johnny Green/PA

Since the launch of Kaiser Permanente’s online member portal on kp.org, four million of the organization’s 9 million members have become My Health Manager users and racked up 116 million visits; they’ve retrieved 32 million test results, ordered 11.8 million prescription refills, and communicated with their physicians via secure email more than 13 million times.

More than 400,000 members have downloaded Kaiser Permanente’s mobile app since it debuted in January of 2012, and these members have clocked up more than 19 million mobile-optimized website visits.

It’s with this member e-engagement prowess that Kaiser Permanente information technology leaders participate in the annual conference of the Healthcare Information Management Systems Society in New Orleans next week.

Morris Collen MD, (second from left) KP’s early digital guru, explains how data was collected and processed in the early 1960s. Cecil Cutting MD, first executive director of The Permanente Medical Group, (behind Collen) observes.

Kaiser Permanente’s digital success stems from its early adoption of computers beginning in 1960 – and to its medical care model that integrates physician offices, hospitals and health plan administration into one system of care.

As an integrated health system, rather than a fee-for-service model, Kaiser Permanente was able to complete its deployment of its electronic health record system, Kaiser Permanente HealthConnect®, in early 2010. Consequently, KP providers can access health information about any member at any of the organization’s locations.

Informatics pioneer saw it coming

Forty-five years ago, in 1968, Kaiser Permanente’s digital guru was Morris Collen, MD. He was a physician and electrical engineer, an unusual career combination in his generation. At that time, he was hot on the trail of one of the first electronic medical records systems, at the cutting edge of computer technology. Dr. Collen will turn 100 on Nov. 12.

Dr. Collen started something big many years ago, and his successors have kept moving forward as pioneers in the medical digital world. When Dr. Collen took KP’s first step into computer technology in 1960, the industry was in its infancy.

Kaiser Permanente members can access their secure health records using mobile phones. They can also use KP’s “Every Body Walks!” mobile app.

KP’s first computer took up an entire room in Oakland, Calif. Since then, through the magic of technology, digital devices have shrunk, and shrunk, and shrunk some more until they can fit in your pocket. Amazing! But Dr. Collen predicted as much in 1998.

“By 2008,” he wrote: “Plan members will hold personal smart cards that will contain their basic health care information, including genetic information, for the predictive practice of medicine. . . Information technology will penetrate every aspect of professional practice, as very small, inexpensive computers pervade clinicians’ offices and examination rooms, nursing stations, procedure rooms, bedsides, clinics and patients’ homes.”

Dr. Collen also predicted – in Kaiser Permanente’s 1966 Annual Report – that patients would welcome a computer between them and their doctors. He said members would be happy their provider could glean instantly so much about their health from a robust and up-to-date electronic record.

Mobile users connect on the fly

The advanced connectivity of Kaiser Permanente’s electronic health record system means that members can go online any time of day or night – on a desktop or virtually anywhere else using a smart phone or other mobile device – and securely access their health information.

They can retrieve test results, order prescriptions, find health information, and make appointments. They can even enroll in online programs that will help them stick to an exercise regimen such as walking, or a nutritional program prescribed for diabetes or other chronic condition.

Perhaps most popular, patients can contact their doctor directly via secure email for advice or follow-up. This access eliminates unnecessary office visits and phone queues.

Getting KP HealthConnect up and running in all facilities, including 37 hospitals and 533 medical offices, makes it the largest non-government electronic health record system in the United States today.

KP well-represented at HIMSS

At HIMSS, a number of Kaiser Permanente experts will present talks on a variety of topics. Among them will be: Shawn Jackman and Nico Arcino who will discuss “Technology and Trajectory of Mobility in a New Health Care Model.” They’ll talk about how providers can stay ahead of mobile technology trends and plan for how their use affects workflow, policy and security.

Also on the bill are: Kate Christensen, MD, and Geeta Nayyar, MD, MBA, who will address the growing use of mobile applications to access health information and discuss how use of these apps can affect patient health and provider practices, and evolve patient-physician relationships.

As a health IT pioneer, Kaiser Permanente will have a strong presence at the HIMSS conference, having received 36 Stage 7 Hospital Awards – the highest level for successful electronic health record implementation. The award recognizes a hospital’s ability to deliver patient care without paper charts.

Since the award was instituted in 2005, HIMSS has bestowed the Stage 7 designation on only 104 of the nation’s more than 5,800 hospitals; 36 of those awards have gone to Kaiser Permanente hospitals.

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When the (poker) chips are down, Sidney Garfield plays it cool

posted on November 20, 2012

By Steve Gilford
Senior consulting historian

Gerald “Jerry” Searcy, center, with nurse Winnie Wetherill (later Neighbor), at left, and an unidentified nurse outside of Mason City Hospital in the late 1930s.

In 1938, when Permanente founding physician Sidney Garfield recruited surgeon Cecil Cutting to join him at Grand Coulee Dam, Dr. Cutting persuaded nurse anesthetist Geraldine “Jerry” Searcy to come along.

Cutting had confidence in Searcy, having worked with her at San Francisco General Hospital after he completed his medical training at Stanford University in the mid-1930s.  He knew she would be an asset to the medical care program set up for Henry Kaiser’s 5,000 construction workers.

Searcy remained with the program from 1938, through the Second World War, until her retirement from the Oakland Medical Center 34 years later. Jerry Searcy told me an anecdote about a personal experience that reflected Dr. Garfield’s managerial style. She liked the story because it helped her to explain why the medical staff was so fond of him.

‘Garfield not bossy’– Geraldine Searcy, 1985. KP Reporter photo.

Her story begins one evening in the Permanente Foundation Hospital in Oakland during the War. The normally busy hospital was unusually quiet that night with little for the staff to do. On that slow night, head physician Garfield just happened to drop by the ward where Searcy was working. His unexpected visit found the staff taking advantage of the quiet by playing a spirited game of poker.

For poker chips, the crew was using pink and white aspirin tablets they’d taken from the supply cupboard. Searcy recalled that Garfield was upset because this misuse of medication was a waste of hospital supplies. He asked them to stop and of course they did – immediately.

The next day the poker players waited somewhat anxiously to see what additional disciplinary measures they might have to face. Garfield surprised them, though. Instead of criticizing them further or meting out some sort of punishment, he donated a set of real poker chips to the hospital.

“From then on,” Searcy remembered: “staff members on call could play poker without disturbing hospital supplies.”

Garfield ‘not at all bossy’

Searcy, who died in 1993, was quoted in a February 1985 KP Reporter edition honoring Dr. Garfield following his death:

“I remember Sid as a very friendly, humble man, not at all bossy, although he did believe in hard work and discipline. Nothing was beneath him, nor beyond him. Once at Grand Coulee, Sid was walking around the hospital without his white coat, looking very youthful with his bright red hair and casual clothes.

“A patient saw him and shouted, ‘Boy! Would you take care of this?’ pointing to his bedpan. Sid wasn’t at all offended. He laughed and emptied the bedpan. Of course the patient had no idea who Sid was,” she said.  She continued:  “Dr. Garfield liked to sing ‘My Heart Belongs to Daddy’ while performing surgery at Grand Coulee.

“To me Sid was a colleague and a friend. He must have been a leader, though he never waved a flag or beat a drum.”

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Millie Cutting: physician’s wife makes her own mark

posted on July 27, 2012

By Ginny McPartland
Heritage writer

Millie Cutting in the early years of Permanente Medicine. Kaiser Permanente Heritage Archives photo

Millie Cutting was the wife of Kaiser Permanente’s pioneering chief surgeon Cecil Cutting, but her influence on the fledgling medical program during World War II contradicts any cliché prescribing the role of a doctor’s spouse. She was a vibrant, energetic force in her own right, a good woman behind a good man, but much, much more.

The Cuttings met in Northern California at Stanford University in the early 1930s. He was training to become a physician; she was a registered nurse with a degree from Stanford. They met on the tennis courts and married in 1935.

During her husband’s nonpaid internship, Millie Cutting worked two jobs – for a pediatrician during the day and an ophthalmologist in the evenings – to pay the bills. He was making $300 a month as a resident when Sidney Garfield, MD, contacted him about joining the medical care program for Henry Kaiser’s workers on the Grand Coulee Dam in Washington State.

Millie was at first reluctant to leave San Francisco to relocate in the desert. But when Cecil convinced her that he would have more opportunity as a surgeon with Garfield than in San Francisco, she was game.  “Oh, she was willing to go along; she had a lot of spirit and enthusiasm,” Cecil Cutting said in his oral history.

“I think with a little reluctance, perhaps of the unknown,” he told interviewer Malca Chall of UC Berkeley’s Regional Oral History Office in 1985. “We didn’t have any money. She had worked during my residency as a nurse, to keep us in food.”  Sidney Garfield was able to match the $300 Cutting was earning at Stanford to get him to Coulee.

A rough start at Grand Coulee

Unfortunately for Millie, things at Coulee didn’t start out too well. John Smillie, MD, writes: “Cecil and Millie Cutting resided in the company hotel. They were flat broke. The young couple had exhausted their resources getting to Washington. Neither of them thought of asking for an advance.”1

“My wife couldn’t take the heat very well,” Cutting told Smillie. “She would lay on the bed with a wet sheet over her; and we didn’t have enough money to eat, really. She would go to the cafeteria and see how far she could stretch a few pennies to eat. Of course, I ate well at the hospital and had air conditioning and everything.

Cecil Cutting, a surgeon, and Millie Cutting, a registered nurse, both graduates of Stanford University, married in 1935. Kaiser Permanente Heritage Resources Archives photo

“She finally learned to come over and sit in the waiting room on the very hottest days. Since then, Dr. Garfield laughed at us and said, ‘Why didn’t you ask me for money?’ We didn’t know enough to do that!”

“At the end of the first discomforting month, Cutting received his first paycheck for $350,” Smillie writes. “He and Millie moved into a remodeled schoolhouse, the largest home in the community, and it soon became the social center for the physicians and the Kaiser executives.”

Millie gets her groove back

During the rest of their time at Coulee, Millie not only got her energy back but she exhibited her strength as a staff nurse and as a community volunteer. Probably her most significant contribution was the development of a well-baby clinic in a community church. As a volunteer, she organized the clinic and went door to door soliciting funds for its operation. She had no qualms about knocking on the portals of the town’s brothels.

“The madams were very friendly,” Cecil Cutting told Smillie. “The community church provided the space, and the houses of ill repute the money – a very compatible community.”

Garfield’s right hand ‘man’ at wartime shipyards

Millie and Cecil Cutting with Kaiser Permanente physician co-founder Sidney Garfield (right) at Oakland Kaiser Foundation Hospital, 1943. Kaiser Permanente Heritage Resources Archives photo

The Grand Coulee Dam was completed in 1940, and the medical staff and their families scattered. The Cuttings settled briefly in Seattle where Dr. Cutting set up a surgery practice. But it wasn’t very long before World War II broke out and Dr. Garfield was called upon again to assembe the medical troops.

Cecil Cutting was the first physician to arrive in Richmond, California, where Henry Kaiser set up four wartime shipyards. Millie Cutting volunteered to work side by side with Sidney Garfield to get the medical care program up and running and to take charge of any job that needed to be done.

She recruited, interviewed and hired nurses, receptionists, clerks, and even an occasional doctor, to staff the health care program that was set up in a hurry in 1942. She smoothed the way for newcomers and helped them find homes in the impossible wartime housing market.

Thoroughly adaptable Millie drove a supply truck between the Oakland and Richmond hospitals and the first aid stations and served as the purchasing agent for a time. As she had done at Grand Coulee, Millie set up a well-baby clinic for shipyard workers’ families, and she opened her home in Oakland as a social center for the medical care staff.

Perturbing postwar perceptions

After the war, Millie and Bobbie Collen, wife of Morris Collen, MD, started a Permanente wives group in 1949. The association created a support system against an often hostile medical establishment that shunned prepaid group practice of medicine as “socialist.” The physicians were not allowed in the local medical society, and the women felt socially ostracized.

“They organized themselves as the Permanente Wives Association, which had a nickname, ‘Garfield’s Girls,’ ” Smillie wrote. “They had dances, parties, picnics and social outings several times a year that were really a lot of fun. The auxiliary. . .became famous for its rummage sales.”

Millie and Cecil Cutting with daughter Sydney and son Christopher, circa 1948 in Orinda, California. Kaiser Permanente Heritage Resources Archives photo.

The Cuttings became good friends with Sidney Garfield, and in fact, he spent periods of time living with them in their Orinda home in the 1940s and 1950s. Cecil Cutting credits Garfield with the couple’s decision in 1948 to adopt their two children, Sydney and Christopher. “He talked us into it,” Cutting said.

Garfield often went to them for advice about business matters, as well. “I think he talked over a lot of things with Dr. Cutting and Millie,” said Smillie in his oral history. “He had a great deal of confidence in their judgment. If they told him he was wrong, he was able to accept it.”

The Cuttings were the friends Garfield chose to share the happy moment of burning the mortgage papers once the renovated Fabiola Hospital (the first Kaiser Foundation Hospital in Oakland) note was paid off.  The private celebration took place in the Cuttings’ home with just Garfield and Millie and Cecil present.

Dr. Cutting worked his way up to become the executive director of The Permanente Medical Group in 1957 and retired in 1976 after 35 years as a major figure in the organization. Millie Cutting continued to volunteer at the Oakland Kaiser Foundation Hospital all of her life. She had to quit in 1985 when she became too ill to leave her house. She died that year at the age of 73. Cecil Cutting received a flood of condolence notes from all the people whose lives Millie had touched.

One woman wrote: “When life seemed just too much, Millie’s unforgettable laughter would ring in my mind’s ear, and the will to tackle life again would be there like a gift from her. She didn’t just give. She was a gift.”

1 John Smillie, MD, Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group, McGraw-Hill Companies, New York, 1991

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KP early physician leader views health care future from 1966 vantage

posted on June 25, 2012

By Ginny McPartland
Heritage writer

Cecil Cutting, MD, led The Permanente Medical Group from 1957 until 1976. Kaiser Permanente archives photo

As we wonder and worry about the fate of health care in America, it’s interesting to look back at how Kaiser Permanente physician leaders saw the future just after the 20-year-old health plan got a firm foothold in the 1960s.

Cecil Cutting, MD, executive director of The Permanente Medical Group, told of his worst fears in a talk to a group of hospital administration graduate students at the University of Chicago on Nov. 17, 1966.

“Looking ahead, there seems little doubt but that our present ‘derangement’ of providing medical care is totally inadequate to absorb the onrush of the technological revolution that is now upon us, even if the rising personnel costs can be absorbed,” Cutting lamented.

“The tempo of the hospital has changed from a relatively easy-going, low cost charity institution to a competitive, high cost one, with third parties paying the costs and becoming ever more critical of hospital management,” Cutting said.

A 1935 Stanford Medical School alumnus, Cutting joined Sidney Garfield when he established a medical care program at the Grand Coulee Dam job site in the late 1930s. During the war, Cutting also took a leading role in Garfield’s Kaiser wartime shipyard program in Richmond, California.

1960s changes threatened traditional medical care delivery

Cutting was talking about the mid-1960s climate that included newly enacted government-paid Medicare-Medicaid programs for the elderly and poor, a flood of new medical technology, health care professionals’ demands for higher pay and a proliferation of union and company health plans for workers.

With the blessing of KP founding physician Sidney Garfield, Cutting laid out the problem: “Today we have many individual, unrelated, competitive hospitals seldom organized among themselves as a team, for the most part with unorganized staffs of physicians, serving an unknown population – a population unknown both in numbers and in health requirements.

“The consequences of continuing along our present path of complete disorganization are staggering and make the need to change methods of organizing medical care inevitable,” he told the group.

Kaiser Foundation Hospital in Oakland, circa 1966. Kaiser Permanente archives photo

Cutting warned that high technology was too expensive for an individual institution to purchase on its own. He said a system should be established in which medical facilities are designated as one of three types: a community preventive health center; a service hospital for routine care, such as trauma, appendectomy, hysterectomy, maternity, hernias, cancer surgery, pediatrics and psychiatry; and a “super-specialty” hospital.

‘Super-specialty’ hospital to optimize high technology use

The highly specialized treatment facility envisioned by Cutting (perhaps the precursor of a center of excellence) would be designed for handling neurological cases, open-heart surgery, megavoltage radiotherapy – the types of cases that required the most sophisticated equipment.

Here, specialists would take care of a sufficient number of patients referred from other facilities to optimize utilization of the equipment and highly skilled staff.

As it happened, Kaiser Permanente was in the process of developing such a system by this time, and Cutting could report its success to his audience. “In Northern California area the Kaiser Permanente program is working along these lines, though it is by no means a finished demonstration,” Cutting said.

“The (Kaiser Permanente) group practice-prepayment arrangement is, in itself, a step toward improving organization of medical care and undoubtedly makes accomplishment of further organization considerably easier to attain.”

Health assessment staff greet a longshoreman ready for his battery of tests, 1961. Kaiser Permanente archives photo

Health center concept proposed

The health center concept, which Cutting called “predictive and preventive medicine,” had already been developed and was in operation in KP Northern California.  “Forty thousand patients a year are being given an extensive health questionnaire (to complete), updated each year, and an automated battery of some 20 test measurements plus 18 laboratory procedures amounting to almost 1,000 different characteristics on each patient,” Cutting continued.

With this information, all recorded in a computer data base, KP physicians compiled knowledge of each patient’s changes from year to year. This information helped physicians to predict illness and to advise patients and their families about how to prevent chronic illnesses such as diabetes, heart disease and cancer.

Annual physicals usually include eye exams, as well as other preventive screenings. Kaiser Permanente archives photo.

Data compiled about whole populations, i.e. KP members, also helped researchers answer such questions as: Can treatment of asymptomatic patients with a slight increase in blood sugar prevent diabetes altogether or merely postpone the disease? With data from a questionnaire about a patient’s psychological state, researchers compared the effectiveness of psychiatric services versus medical office visits for reducing total visits for emotionally disturbed patients.

Too many specialists spoil the broth

Cutting complained to his audience that medical schools were turning out too many specialists, a trend that threatened basic medical care. “It would appear that the rush for super-specialization may be leaving behind an ever widening gap in well rounded, competent medical judgment.

“Though the individual episode of care may be superb, it certainly does little for the orderly development of efficient, economical medical care as a whole.”

In what must have surprised many, Cutting suggested that medical education should develop a new type of medical doctor: the preventive, predictive specialist. “Following the natural development of disease of entire families over long periods, alerted to early changes through the screening program, he becomes a health specialist.”

Today, both primary care and preventive medicine are specialties recognized by the American Board of Specialties.

A pilot Health Education Center opened in Oakland in 1967. Sidney Garfield, MD, champion of Total Health, stands next to the transparent woman, one of the center's displays.

Kaiser Permanente has advanced Garfield and Cutting’s ideas about preventive care and health appraisals in a variety of ways over the decades. KP physicians promoted healthy eating and exercise for the workers in the World War II Kaiser Shipyards, and they began offering preventive testing in the 1950s for members of the longshoremen union and other groups.

KP’s ‘Total Health’ concept emerges

In the 1970s, health education centers were established to teach patients how to stay well; Garfield’s Total Health Research Project launched in the 1980s led to the opening of special centers where  healthy patients received their routine care.

Centers for preventive medicine functioned within KP for many years, largely giving way to periodic screenings for particular diseases such as breast and colon cancer, heart disease, hypertension and diabetes. Healthy Living programs, an expansion of member health education, have flourished in the past decade offering many classes in good nutrition, exercise, smoking cessation and stress reduction.

Cutting ended his talk with a few wishes for the future: community institutes to teach people to preserve their good health, easily shared electronic medical records, and above all, cooperation among health organizations to provide a broad spectrum of care – from the preventive to the most complicated.

“When (all) care, whether in super-specialty hospitals, service hospitals, extended care, office or home, is correlated . . . I will begin to see hope,” he said.

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Quality of care: Always foremost in minds of Kaiser Permanente leaders

posted on February 29, 2012

By Ginny McPartland
Heritage writer

First in a series
In the beginning of the modern era of medicine there were doctors and patients.  To judge the quality of care was to ask: Did the patient live? Is the patient thriving? Doctors had little science to back up their methods. They followed conventions and did what they thought was best for the patient. If a doctor went wrong, no formal mechanism existed to correct his (or her) ways.

Hard to imagine how we got from such early simplicity to today’s complicated state of quality affairs. Our 2012 definition of quality encompasses a myriad of considerations:  timely access to care, science-based treatment, adherence to well-defined practice protocols, and appropriate use of technology. Preventive care screenings, such as mammograms and colon studies to catch cancer early, and access to health education so patients can learn to avoid disease are key factors in assessing the quality of care of a provider organization.

Figuring out the best way to judge quality of care has been a monumental quest pursued by health care providers and consumers alike since the early 1950s. This pursuit has been embraced by numerous medical, government and consumer agencies in the past 50-plus years, creating a veritable alphabet soup of regulatory and review/rating organizations with varying degrees of effectiveness and longevity.

Hannah Peters, MD, a women’s physician in the World War II Kaiser Shipyards, studied the female workers’ adaptation to heavy labor.

Further complicating the issue of quality is the fact that everything doctors, hospitals and health plans undertake – staff recruitment and education, research, and technology upgrades – affects quality. So it’s difficult, if not impossible, to talk about quality without looking at these topics as well. So the subject of quality is all-encompassing and, at times, overwhelming.

A case study of Kaiser Permanente’s initiatives over the decades to assess and improve quality of care reveals many different approaches and different boards and committees formed to respond to industry trends and to ultimately crack the quality nut.

In many instances, Kaiser Permanente was in the forefront of the various quality movements, often with the intention of proving its own worth to a skeptical world of traditionalists who didn’t like prepaid group practice. At other times, Permanente was pioneering new methods of care delivery and conducting crucial quality research that would lead the way for what came to be called quality assurance, initially for health maintenance organizations (HMO) and later for all forms of managed care.

Permanente physicians came from academic tradition

Starting out in the World War II West Coast shipyards, Sidney Garfield and Henry Kaiser knew the quality of care had to be the best possible to make sure the often sickly workers would be fit for dirty, hard and stressful work. So they used the latest methods they knew – and could learn about through research – to be on top of their medical game. Coming from an academic medical center at Los Angeles County General Hospital, Garfield understood the benefits of research, collaboration and continuous quality improvement, a term unheard of at the time.

Garfield hired like-minded contemporaries, such as surgeon Cecil Cutting, internist Morris Collen, and gynecologist Hannah Peters, all socially conscious and oriented toward innovation, to carry out the wartime program. Learning all the time, these physicians developed new treatments and published their results during and after the war.

Inundated with pneumonia patients, Collen uncovered new ways to treat the often deadly condition. Treating pneumonia patients with horse serum and sulfa drugs, Collen was able to save many lives, even before the “wonder drug” penicillin became available to treat civilians at war’s end.

Hannah Peters, a German native who migrated to New York in 1934, studied women shipyard workers’ ability to adapt to heavy, industrial work. She noted how a woman’s menstrual cycle was affected by the carbohydrate-rich diet necessitated by the physical demands of welding and other shipyard jobs.

She and her colleague gynecologist Duncan Footer published their results in a 1946 issue of the Kaiser Foundation Bulletin, as well as in national medical journals. Peters went on to become the leader of the Laboratory for Reproductive Biology in Copenhagen and published many articles on women’s health.

Postwar health plan set aside funds for research and education

San Francisco pediatrician John Smillie checks the health of two young sisters and their doll, circa 1960.

After the war when the Permanente health plan was opened to the public, quality of care continued to be a top priority. With 5% of Kaiser Foundation revenues guaranteed by its charter for education, research and community benefit, the Permanente physicians continued to form bonds with academic institutions to learn, teach and conduct research.

Sidney Garfield always put an emphasis on research and continuing education. Dr. Collen recalls: “When he (Garfield) set up the Department of Medical Methods Research (1961 in Northern California), he always maintained a close association with it. He always had important projects that he wanted our department to carry out because he was very self-critical of our organization. Although he was of course very proud of what he had conceived and accomplished, he always felt we should try to do better.”

Collen adds that having a robust research program helps attract good physicians to KP. “The best quality of care involves a simultaneous interest in teaching and in research, in addition to patient care.”

Southern California pioneers had eye on the quality ball

In Southern California, the physician group was also diligent in the selection of physicians from its beginnings in the early 1950s. Sam Sapin, quality pioneer, explains: “The SCPMG (Southern California Permanente Medical Group) had many intrinsic or built-in quality assurance mechanisms.”

A maternity nurse tends to newborns at a KP hospital, circa 1965.

These included: careful selection of physicians and imposing a probationary period of two to three years before election to partnership; and an informal but very effective form of physician peer review because of KP’s group practice model. Group practice also provided the opportunity for collaboration with colleagues and specialists to avoid inappropriate care and mistakes.

Sapin says other quality ensuring factors included mandatory physician continuing education, ongoing sharing of inpatients and outpatients and their medical records as well as the accountability for quality of care vested in chiefs of service and medical directors who could withhold merit and longevity salary increases. Another key factor:  there was no incentive for overutilization or performance of unnecessary procedures and no incentive to withhold appropriate care.

Henry Kaiser triggers review of KP hospitals in 1959

Aside from the original and sincere intent to be the best in care, the Permanente physicians’ first stab at quality assurance came in 1959 when Henry Kaiser asked the question of Permanente health plan executive Clifford Keene, MD: “Do our hospitals provide quality of care? John Smillie, MD, an early KP San Francisco physician, recounts in his oral history: “Dr. Keene thought for a moment and he said, ‘I don’t know. I don’t know how we can judge how good the care is in our hospitals, but I’ll find out for you.’

Emmett Lowrey, MD, leads a discussion among early Permanente physicians about the results of an X-ray examination.

“So Dr. Keene then commissioned Dorothea Daniels (KP’s first female hospital administrator) to do a study of hospital quality of care in all Kaiser Foundation Hospitals, not just Northern California, but in Southern California, and Oregon and Hawaii. She came back, I think in a year, with a very thorough report, which showed that in some hospitals the quality of care could be improved, and in other hospitals it was excellent. But it was a very honest and straightforward report,” Smillie said.

At that time, formal external quality assessment and documentation did not yet exist. The Joint Commission on the Accreditation of Hospitals had formed in 1952 and begun a voluntary accreditation program, but before the advent of Medicare in 1965 no government, employer or consumer influence had made itself felt in the regulation of medical care. That situation would soon change and the age of innocence for physician and hospital quality review was giving way to a much more complicated and anxious time.

Next time: The late 1960s and 1970s bring much conversation, soul-searching and anxiety about quality of care.

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