Posts Tagged ‘Sam Sapin MD’

Southern California Permanente Medical Group celebrates 60 years

posted on January 8, 2014

By Steve Gilford
Senior consulting historian

Raymond Kay, MD, friend of Garfield and early leader of the Southern California Permanente Medical Group, playing ping pong at the Desert Center  hospital site.

Raymond Kay, MD, friend of Kaiser Permanente founding physician Sidney Garfield and early leader of the Southern California Permanente Medical Group, playing ping pong at the Desert Center hospital site. Kaiser Permanente Heritage photo

As an independent historian with a long-standing interest in Kaiser Permanente, I was fortunate to be invited to the daylong 60th anniversary celebration of the Southern California Permanente Medical Group, held recently in Anaheim, Calif.

The event was to mark the medical group’s formal start in 1953 when 13 Permanente physicians, including Ray Kay, the first medical director, signed a partnership agreement that officially formed SCPMG.

The group’s origin actually goes back to 1943 when Henry J. Kaiser asked Permanente co-founder Sidney Garfield, MD, to establish a health care plan for workers of the Kaiser Steel mill in Fontana.

Today, SCPMG has more than 6,000 physicians practicing in 14 accredited Kaiser Foundation Hospitals and more than 190 medical office buildings.

Pride a theme of celebration

As I observed the events of the day (Sept. 28, 2013), I heard Permanente physicians express pride in the organization and its legacy. But at first I wasn’t entirely sure the expressions were genuine, or if it was similar to the type of pride shown for a football team or one’s alma mater.

As the day unfolded, it became increasingly clear that this was an authentic professional pride rooted in SCPMG’s 60-year history of trials and triumphs.

Pride in the organization can be traced back even further, to the tiny 12-bed hospital Sidney Garfield built in 1933 on a parched and lonely piece of desert land in one of the most physically inhospitable places in the United States.

The organization that sprang from that little frame building in the Mojave Desert, with its one doctor and one nurse, was being celebrated by thousands gathered together in one of the most populous and powerful metropolises of the nation.

Roll call gets vociferous response

Edward Ellison, MD, the SCPMG executive medical director, began the day by calling the roll of Southern California’s medical centers represented at the gathering.  Each medical center team responded to the call with a spontaneous cheer that resonated across the large hall.

There was no question that these physicians were enthusiastic, but it was not yet clear to me just why they were responding with such vigor. Was it like the way people in a talk-show studio audience react when someone mentions their hometown?

Was it just because they had found a comfortable place to practice medicine outside the increasingly stormy arena of fee-for-service medicine, relieved to be insulated from some of the stresses their professional colleagues were facing?

Frank Murray, MD, Kaiser Permanente Southern California medical group executive director, XXX. with Sam Sapin, MD. Sapin was instrumental in the development of the regional graduate medical education program, which opened its first residency program in 1955.

Frank Murray, MD, at left, Kaiser Permanente Southern California medical group executive director, 1982-1993, with Sam Sapin, MD, pediatric cardiologist and SCPMG quality leader.

Or was it truly because they were recognizing that they were a part of an organization that was truly special, with a leadership that encouraged them to practice preventive care and to take great care of their healthy members, as well as their sick patients?

Celebrities tout Permanente’s national role

As a part of the proceedings, there were dramatizations featuring Henry Kaiser, Sidney Garfield and even Rosie the Riveter – all well done and entertaining. They set the stage for Kevin Starr, noted California historian and author, and Nancy Snyderman, MD, chief medical editor, NBC News, and award-winning journalist.

The celebrities’ presentations put the achievements of Kaiser Permanente into perspective, each emphasizing the contribution of the organization to the nation’s health care.

Starr and Snyderman were the stars of the day, but for me the day’s high point was an onstage discussion by the four surviving SCPMG executive medical directors – Frank Murray, MD, 1982-1993, Oliver Goldsmith, MD, 1994- 2004, Jeffrey Weisz, MD, 2004-2011, and Edward Ellison, MD, current executive director.

They presented the organizational challenges that they had faced in their time and told how they had overcome them.

Through all their recollections flowed a strong streak of natural idealism that had helped them shape their responses to the challenges of their time at the helm. Their remarks – more than any other presentation – made it clear that SCPMG leaders created and passed on a strong legacy that was to be treasured, defended and enhanced.

As the day drew to a close, Dr. Ellison summed up what he felt was special about Permanente Medicine and SCPMG. We are building infrastructure for the future . . . I am confident that our approach to achieving the total health of our patients in mind, body and spirit is the successful path to that future.

“Our conquering, enduring spirit, combined with our passion for medicine and our caring from the heart, will sustain us for the next 60 years,” he told the group.

Often, when you hear such presentations made by leaders in front of their staffs, if you listen carefully you can hear quiet undertones of mildly cynical scoffing or snickering from the rank and file who may have a quite different perspective on the relation between idealism and reality.

That afternoon I was listening closely for that tell-tale buzz from among the 3,000 people in the hall. I didn’t hear it.

What I did hear was enthusiastic agreement with what Dr. Ellison was saying. I understood then that the pride I had sensed in the responses to his morning roll call of the medical centers had been genuine and had only been enhanced by the day’s focus on the achievements and potential of Permanente Medicine.

I left Anaheim with a renewed sense of pride in my association with Kaiser Permanente, for my modest part in searching out, saving and communicating its history to new generations of physicians who will preserve and expand the legacy begun by its founders.

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Kaiser Permanente Sacramento founders spread wings in bustling 1970s

posted on October 17, 2013

By Ginny McPartland
Heritage writer

Millie Kahane, a former professor of nursing at California State University, Sacramento, and John Mott, MD, collaborated to open the Kaiser Permanente Health Appraisal clinic in Sacramento. The center was staffed by some of the health plan’s first nurse practitioners. Photo taken in the early 1970s by a co-worker.

First of a series

It’s 1970 and Kaiser Foundation Health Plan’s operation in Sacramento is just five years old. The state of California and the federal government have both recently set up health benefits for their employees with Kaiser Permanente as a popular option.

The Northern California Health Plan is quickly approaching its million members mark, and the Sacramento facility is overflowing with patients.

Meanwhile, Mildred “Millie” Kahane, BS, MS, a New York transplant teaching nursing at California State University, Sacramento, thinks her students are bright enough to contribute more in the burgeoning field of health care. The destiny of nurses, she believes, is to rise above the traditional hospital bedside role and to take on more responsibility in an outpatient setting.

She believes her students can learn new skills that could eventually be included in a bachelor of science nursing program and that these advanced nursing capabilities would provide the core content upon which to build clinical specialties.

John Mott, MD, physician-in-chief at Kaiser Permanente Sacramento, is facing increasing pressure to welcome and serve new members. His resources for providing primary care and new member health assessments can’t keep up with the demand. What is he to do?

Fortuitously, Mott and Mrs. Kahane have occasion to meet – through her husband Kaiser Permanente Sacramento chief of OB-GYN Albert Kahane – and their collaboration sets in motion a revolutionary program to elevate the nursing role and to solve Mott’s shortage of primary care providers.

Some of Millie Kahane’s students will become “nurse practitioners,” a title unheard of at the time in Sacramento County, and Kaiser Permanente members will get comprehensive evaluations in what will become known as the Department of Preventive Medicine.

Origin of advanced practice nursing

The story of Mrs. Kahane and her hand-picked nurse practitioner pioneers was not unique in the 1970s health care landscape. Indeed, medical providers throughout the United States were looking for solutions to a manpower shortage. In that era, the federal government provided special funding to identify ways to maximize health care dollars.

Within Kaiser Permanente in particular, physicians in Southern California, Oregon and Hawaii began to train nurses to examine seemingly well patients and identify any abnormalities for follow up with a physician.

Eileen O’Hagan McCauley followed Millie Kahane in 1975 as the leader of the Sacramento preventive care nurse practitioners group. Photo taken in late 1970s by a co-worker.

Pediatrician Sam Sapin, MD, in Panorama City worked with Southern California Permanente Medical Group Director Raymond Kay, MD, to train nurse practitioners to provide well-child check-ups, along with physicians.

In Oakland in the early 1970s, Drs. Morris Collen and Robert Feldman employed NPs in the “Multiphasic,”  an annual physical program originally set up for the longshoremen’s union in 1951.

After nurse practitioner programs were well established in Northern California, The Permanente Medical Group developed a certification process for those who were to work as nurse practitioners within the organization. This process later helped Kaiser Permanente nurses meet California nurse practitioner requirements.

The first formally educated Kaiser Permanente nurse practitioner was Linda Lee, who was one of  Mrs. Kahane’s students at Sacramento State. Upon graduation, she attended the nurse practitioner program established by Henry Silver, MD, at the University of Colorado in 1965.

Silver’s program was the first university-based pediatric nurse practitioner program in the United States. After completing the program, Lee came back to California and worked with Sacramento Kaiser Permanente Chief of Pediatrics Clifford Skinner, MD.

Synergistic forces converge in Sacramento

Why is the story of the Sacramento Kaiser Permanente Nurse Practitioner and Preventive Medicine Program of the 1970s remarkable?  Looking back after 40 years, the program’s pioneers – many still working for Kaiser Permanente – marvel at the phenomenon of a close-knit group of advanced practice nurses who loved their mentors and their patients and whose lives were marked indelibly by the experience.

Nurse educator Mildred Kahane and Physician-in-Chief John Mott’s alliance to develop a nurse practitioner program found fertile ground in the hearts and minds of certain of Mrs. Kahane’s graduates. In 1970, Mrs. Kahane set completion of a bachelor of science degree as the basic program requirement and recruited four candidates to begin work (and training) in the Health Appraisal Evaluation center to be located in an older Kaiser Permanente building at 3240 Arden Way, Sacramento.

Carl Henriques, MD, a Sacramento Kaiser Permanente allergist, became the medical director and instructor of nurse practitioners in the Department of Preventive Medicine in the 1970s. He is pictured here with his wife, Thelma.

Kaiser Permanente allergist Carl Henriques, MD, formerly a general practitioner in Susanville, Calif., became the center’s physician leader and primary teacher. As the program progressed, the University of California at Davis Medical School was developing a mid-level practitioner master’s in Health Services program for nurses.

UCD lacked clinical facilities, which Kaiser Permanente had. Eventually KP and UC partnered, and UC students were able to enhance their clinical experiences at Kaiser Permanente with Mrs. Kahane and Dr. Henriques as members of the UC clinical faculty. Kaiser Permanente nurses were given the opportunity to apply their education and training toward the master’s degree.

Next time: Kaiser Permanente preventive care patients benefit from more time with their provider.

This blog is dedicated to the memory of Eileen O’Hagan McCauley and Linda Lee (both deceased), two of the first NPs at KP Sacramento, and the late Carl Henriques, MD.

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Southern California Kaiser Permanente doctors nurture academic culture

posted on February 13, 2013

By M. Rudolph Brody MD and Sam Sapin MD Kaiser Permanente Southern California

Rudy Brody, MD, second from left, takes residents on rounds at Los Angeles Medical Center.

First of Two Parts 

Permanente’s pioneering physicians started out in the 1940s with the idea of developing an academic environment in which to practice medicine. Accustomed to the university-based hospitals in which they got their training, these not-so-traditional doctors relished the idea of keeping their strong connection to academia. Group practice, which allowed for convenient consultation with colleagues, was the perfect vehicle.

In the late 1940s, Southern California Permanente Medical Group physicians presented interesting and challenging cases for their peers twice per week at the medical centers. More in-depth discussions took place at half-day departmental educational activities that included organized rounds at various hospitals, teaching and research.  Often the medical group hosted visiting professors who presented and led discussions.

Rudy Brody, MD, is the retired director of the Center for Medical Education at the KP Los Angeles Medical Center.

In Northern California, The Permanente Medical Group physicians were taking a similar route. Doctors were given a half day a week to pursue academic opportunities, including teaching, learning and research. By 1969, San Francisco and Oakland medical centers had graduate medical education programs, and each facility had a chief of staff for education.

Beginning in 1955, SCPMG invited medical experts renown in their fields to lead specialty symposia and share new clinical information. Research, mainly on clinical topics, flourished. Without knowing it, SCPMG physicians were practicing in an environment that met the definition of an academic medical center.

Cross-pollinating medicine and academia

What is an academic medical center? Let us take you back one hundred years in American medicine to explain:

In 1910 the Carnegie Foundation asked educator Abraham Flexner to review the quality of the 155 medical schools then operating in the United States and Canada. Flexner visited each one of the schools and prepared a voluminous report that would result in all but five of the schools being declared deficient and forced to close.

Sam Sapin, MD, in 1979. Sapin was SCPMG’s first director of Education and Research, taking on that position in 1972. In this capacity, he oversaw the development of residency and other educational programs.

The Flexner Report spurred a revolution in medical education, and the academic standards set at the time of its release are still pertinent today. In his investigations, Flexner identified Johns Hopkins University School of Medicine as the model for all institutions qualified to train new physicians.

The Johns Hopkins model set down three must-haves for an institution qualified as an academic medical center: 1) a clinical setting where new physicians can gain experience treating patients, 2) high quality teaching and 3) a research program.

Academic bent attracted like-minded colleagues

Starting out a few decades after the Flexner Report’s release, Kaiser Permanente pioneers understood the value of high-quality physician education.  Our early physician leaders created educational opportunities at the medical centers and encouraged all doctors to participate. Many physicians taught at local medical schools. With this academic mindset, SCPMG attracted many new physicians who had recently finished their post-graduate residency and/or fellowship training.

With a large clinical practice and excellent continuity of care, Kaiser Permanente medical centers also began to attract medical students looking for a clinical rotation. Next, residents from local university residency programs came to Kaiser Permanente for an elective experience. This led to residents affiliated with medical schools rotating through the Fontana and Los Angeles Kaiser Permanente medical centers.

In the mid-1950s, SCPMG physicians began to ask themselves: Why not develop our own independent residency programs? The three assets that Johns Hopkins University saw as vital to an academic medical center – opportunities for clinical experience, education, and research – all existed within Kaiser Permanente Southern California.

First SCPMG residency program launched

Led by OB-GYN physicians T. Hart Baker and Jack Halett, the first independent residency program was begun in 1955 at Kaiser Permanente Los Angeles. Dr. Baker, who later became the Southern California regional medical director, had a strong academic background and proven administrative abilities. He teamed up beautifully with Dr. Halett, who had an upbeat personality and a passion for research.

During the early years, a number of the graduates of our OB/GYN Residency Program stayed on after their residencies and devoted their professional careers to SCPMG. These included Ruth Nicoloff, MD, Fred Miyazaki, MD, Harry Richards, MD, and Doug Taguchi, MD.

T. Hart Baker, MD, retired OB-GYN physician, was instrumental in launching the KP Southern California OB-GYN residency program in 1955.

Started in 1971, the pediatrics program initially had one resident, Richard Mittleman, MD, then added Daisy Dolorfino, MD, Jim Heywood, MD, Mary Ellen Friedman, MD, and Phil Mattson, MD. All but one of these pioneer pediatric residents continued their careers at what later became the Baldwin Park Medical Center. Dr. Mattson continued his career at SCPMG in San Diego.

Graduate physician education expands

In the ensuing years, residency programs were started in several other KP medical centers: family medicine at Fontana; internal medicine, general surgery, pathology, urology and pediatrics at Los Angeles; internal medicine at West Los Angeles; and family medicine programs in Orange County, Riverside and Woodland Hills.

Vince Roger, MD, was key to the development of the Family Medicine Residency in Fontana. Dr. Roger also oversaw the launch of the Sports Medicine Fellowship in Fontana, which Aaron Rubin, MD, and Bob Sallis, MD, have directed since 1990.  Our sports medicine program was among the first 20 that were accredited in the United States in 1993.

Today, SCPMG trains more than 300 residents and fellows in 27 independent residency and fellowship programs in six of Kaiser Permanente’s Southern California medical centers.  About 150 residents at various GME programs in Southern California, including UCLA, University of Southern California, UC Irvine and Loma Linda Universities, rotate through our medical centers for a portion of their training. We can afford to be highly selective because we receive more than 7,500 applications each year for 100 available positions.

Bob Sallis, MD, a champion of KP’s “Every Body Walk!” campaign, and Aaron Rubin, MD, co-direct the Southern California Permanente Medical Group’s Sports Medicine residency program, launched in 1990.

Many people have contributed over the decades to the success of our residency programs. Our list includes our longtime Los Angeles residency program directors:  Jack Braunwald, MD, Steve Woods, MD, Ted O’Connell, MD, Thomas Tom, MD, Jimmy Hara, MD, Aroor Rao, MD, Craig Collins, MD, and Scott Rasgon, MD.

Also deserving recognition are: Tim Munzing, MD, program director, Orange County; Walter Morgan, MD, program director, Riverside; Dennis Kim, MD, physician director of the Center for Medical Education; and A. Robert Kagan, MD, an internationally known radiation oncologist.

The growth and prestige of our educational programs result from the work and support of many professionals. We have mentioned some of them in this article, but we realize that many more deserve credit and praise for their contributions.

Next time: Southern California Kaiser Permanente residents take their care to the community.

M. Rudolph Brody, MD, is the retired director of the Center for Medical Education at the KP Los Angeles Medical Center. A pediatrician, he helped create and develop SCPMG’s Pediatric Residency Program and was the first pediatric residency program director (1970-1990). He was the regional coordinator for all the Southern California Residency Programs from 1983-1992.

Sam Sapin, MD, a retired pediatric cardiologist, was SCPMG’s associate medical director for Clinical Services from 1982 to 1990 and consultant for Clinical Services until 1994. Sapin was SCPMG’s first director of Education and Research, taking on that position in 1972. Sapin was also a major influence in the development of quality assurance methods.

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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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Birth of the National Committee for Quality Assurance

posted on March 21, 2012

By Ginny McPartland
Heritage writer

Fourth in a series

Heart specialists of the Southern California Region's Sunset Medical Center go over videotapes at the conclusion of a cardiac catheterization. KP physicians draw on each other's expertise to provide high quality care. KP 1985 Annual Report photo

How good was the problem-based approach to quality assessment developed in the early 1970s by Kaiser Permanente’s pioneers Len Rubin, MD, and Sam Sapin, MD? Soon after its unveiling, the Comprehensive Quality Assurance System was to be put to the test.

In 1979, at the behest of the federal Office for Health Maintenance Organizations (HMOs), the first incarnation of the National Committee for Quality Assurance (NCQA), was formed. Sponsored by the Group Health Association of America and the American Association of Foundations for Medical Care, the committee invited Sapin and Rubin to join.

In short order, the committee adopted Rubin’s problem-focused review method. NCQA’s emphasis was on identifying and correcting problems, and traditional audits were not required, reported Sapin who served NCQA as a board member and surveyor from 1980 to 1987.

Sapin and Rubin knew the review method worked because they had used it to evaluate KP care in both Northern and Southern California. The KP scheme had two levels: first, identifying possible trouble spots by a variety of means and judging the problems according to 56 monitoring criteria; and second, to fix the problem through process change.

Sapin describes the Southern California Permanente Medical Group regional quality reviews of the 1980s: “The program began with a modest number of criteria, and regular reports were distributed to chiefs of service, medical directors and administrators.  Medical centers were identified only by code number. The results were enclosed in a bright yellow folder. We hoped to put the recipients in a receptive frame of mind for their easy-to-recognize quality of care monitoring report,” Sapin explained.

The Permanente Medical Group executive director Bruce Sams, Jr., MD, featured in the 1988 annual report, noted the group practice model gives KP physicians more control over the quality of care than their counterparts in fee-for-service practice. KP 1988 annual report photo

“During the 1980s, these regular reports appeared to generate more quality assurance activity than did the previous classic (traditional) medical audits,” Sapin said.

National quality group loses financial support

NCQA floundered in the early 1980s due to the withdrawal of financial support. “NCQA’s status is presently precarious unless the parent organizations, the HMOs which are surveyed and some of the states, provide funds for its operation,” Sapin reported to the KP board of directors in 1983.

Even though member HMOs and the Office of HMOs inWashington, D.C., were satisfied with the surveys, there was an undercurrent pushing for a review agency independent of HMOs. James Doherty, CEO of the Group Health Association of America for 15 years, said in 1996, “HMOs needed to subject their operations to external review by an independent quality assurance body.”

NCQA regenerates and launches renewed mission

In 1990, the NCQA managed to get funding to reconfigure as an independent agency with a $308,000 grant from the Robert Wood Johnson Foundation and matching funds from HMOs. The board was reconstituted to have 20 members, the majority representing purchasers (largely employers) of care, health plans or consumers.

John Iglehart, editor of Health Affairs journal and national correspondent for the New England Journal of Medicine in the 1980s, was interviewed for the KP publication Spectrum, Spring 1987.

Six physicians, including four medical directors of managed care plans, and Dr. Thomas R. Reardon, a trustee of the American Medical Association, also served on the new NCQA board in the 1990s, according to a 1996 New England Journal of Medicine (NEJM) article by John K. Iglehart, then NEJM national correspondent and editor of the Health Affairs journal. (Iglehart was KP’s vice president of government relations in Washington, D.C., from 1979 to 1981.)

The author notes, “Although strong ties still exist (with managed care leaders), the NCQA is a conduit through which employers apply pressure on health plans to continually raise their quality horizons. This pressure creates a tension that reverberates throughout the NCQA’s relationship with health plans.”

Consortium hammers out first HEDIS measures

With the reconfigured NCQA, Kaiser Permanente and six other large employers went to work to fashion quality performance measures. These measures, which cover inpatient and outpatient care, would come to be known as HEDIS or HMO Employer Data and Information Set.

In the 1993 Quality Agenda in Action report, KP CEO Dr. David Lawrence wrote: “HEDIS is the basis for. . .a national effort of 30 major managed health care plans and a group of consumers and business representatives. . .to develop a system that will enable (purchasers) to compare health plans on the basis of quality indicators.”

NCQA released its initial set of quality measures in 1991, and about 330 health plans measured their performance according to the HEDIS system and reported their results to employers, Iglehart reported in his NEJM article.

KP's 1986 annual report focused on quality of care. The report covered many facets of quality, including cost, structure of assessment, data availability and the role of government.

He wrote: “The NCQA standards are evolving. . .A recent version (HEDIS 2.5) incorporated more than 60 performance indicators that cover quality of care, access to and satisfaction with care, the use of services, finances and management. Most indicators, however, assess administrative performance or utilization rather than quality of care.

“The nine quality measures focus on process, particularly the use of preventive services, which can be readily measured. Only two indicators measure a health outcome (low birth weight) or a proxy for a health outcome (hospitalization rates for patients with asthma),” Iglehart wrote.

On its Web site today, NCQA touts its HEDIS system as the industry standard for comparison of health care providers. “HEDIS allows for standardized measurement, standardized reporting and accurate, objective side-by-side comparisons . . . We work to make sure that all measures address important issues, are scientifically sound and are not overly burdensome or costly to implement.”

Examples of current HEDIS measures include: Advising smokers to quit; antidepressant medication management, breast cancer screening, cervical cancer screening, children and adolescent access to primary care physician; children and adolescent immunization status; comprehensive diabetes care; controlling high blood pressure; and prenatal and postpartum care.

Next time: 1990s begin with supercharged KP quality agenda

 

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Permanente pioneers step out to blaze their own quality trail

posted on March 14, 2012

By Ginny McPartland
Heritage writer

Third in a series

Leonard Rubin, MD, Northern California quality expert, and Sam Sapin, MD, his Southern California counterpart, go over charts. Kaiser Permanente 1986 Annual Report photo

As the 1970s drew to a close, physicians and quality reviewers nationwide were probing and struggling to make a faulty “medical audit” system work to evaluate and improve the health care of millions of Americans, young and old, well and sick, rich and poor.

In three Kaiser Permanente regions, physicians and quality auditors had received federal grants to apply the medical records retrospective review or traditional method endorsed by state medical associations, the Joint Commission for Accreditation of Hospitals (JCAH), and Medicare and Medicaid officials.

Southern California, Hawaii and the Northwest KP regional medical groups obtained three-year grants under the EMCRO (Experimental Medical Review Organizations) project to put the traditional medical audit system into practice and find out how well it worked. It didn’t.

'Quality assurance is a kind of umbrella to keep the environment safe for the patient' – Mike Chappin, MD, Hawaii Permanente physician, KP employee magazine, Spectrum, winter 1987

Northern California quality pioneers forge their own model

In Northern California, quality guru Len Rubin, MD, PhD, had taken a different path. “I think they (Northern California) were a bit smarter than us (SCPMG),” admitted Sam Sapin, MD, KP Southern California quality leader in the 1970s and 1980s.

As early as 1973, Rubin was piloting a new quality assessment method in all 13 of the Northern California KP medical centers. Rubin’s system, called Comprehensive Quality Assurance System (CQAS), had reviewers checking medical records of patients who had just been discharged from the hospital. The emphasis was on finding deficiencies in real time and auditing problem cases for questionable practices that may have contributed to bad outcomes.

“He (Rubin) really pioneered the problem-focused approach to quality of care assessment and assurance,” Sapin said. “His motto was and is, “Find out what’s wrong, not what’s right, then fix it.” Rubin published his CQAS protocol in 1975 for the American Group Practice Association.

Best to measure process or outcome?

In developing his model, Rubin was acutely aware of the difficulty of defining the relationship between process – delivery of care and drug administration – and the outcome of those treatments. Rubin argued that there are many “outcomes” in the continuum of care and many factors don’t affect the ultimate outcomes of good health, ability to return to work, or at the other end of the spectrum death or chronic illness or disability.

Joel Kovner, a doctor of Public Health and director of the Medical Economics Department for the KP Southern California region, was a key player in quality assurance research. KP photo 1974

“As can be seen, there are endpoints here (or outcomes) relating to many departments (laboratory, record room, physician, pharmacy, patients, etc.). Often the outcome of one process is the input for another,” Rubin wrote in his 1975 CQAS publication.

“Further confusion lies in the time-dependence of outcome. The outcome may differ enormously, depending upon whether it is being measured immediately after treatment, several months after treatment, or several decades after treatment,” he continued. “Latent drug effects only now becoming known completely invalidate previous judgments that some outcomes were good in the long term. He concluded: “There is no way to measure ‘ultimate outcome.’ ”

Different schools of thought cloud issue

Sapin reported that at this time debate was raging between the “outcome” and the “process” people. “The process people say outcomes are too difficult to measure and interpret correctly; one should only compare outcomes of cases of comparable severity and one should also take into account all of the intervening variables (e.g. patient compliance, income level, lifestyle) which cannot be controlled by the provider and yet will affect the outcomes.

“On the other hand, the outcome people say don’t bother to assess process because many processes do not correlate well with outcomes and some may even lead to bad outcomes. The safety and efficacy of many of the things we do to and for patients have never been scientifically validated,” Sapin said in his 1983 presentation to the Board of Directors, “Historical Perspectives on Quality of Care.”

In 1973 as Rubin tested and refined his method, Jim Vohs, KP’s CEO, set up the KP board of directors’ Subcommittee on Correlation of Quality of Care and established a new department to focus on quality. Vohs also established the Interregional Quality Assurance Committee (IRQAC), with quality representation from all KP regions.

Ohio Permanente physician Sam Packer examines young patient. Physicians in all regions began participating in quality efforts in the 1970s. KP photo

The group came together at least once a year to compare quality notes. Giving program-wide quality a high priority, Vohs accompanied surveyors on all the committee’s facility visits in the regions.

Rubin’s system had an almost twin at the state level

Ironically, in the early 1970s the California Medical Association (CMA) and the California Hospital Association (CHA), responding to the rise of malpractice insurance rates, devised a “problem-focused” or “generic-screening-criteria” method similar to Rubin’s. Even though both agencies required the traditional medical audit for their member organizations, they decided to use a different method to identify outcomes that could become subjects of malpractice lawsuits.

The CMA-CHA method called for the review of medical records upon a patient’s discharge to identify adverse outcomes. In reviewing charts, they measured quality according to 20 standards to find problems. Examples of the screening criteria were unplanned removal of an organ, repeat of an operation during the same hospital stay and development of a heart attack after admission. CMA-CHA’s “Medical Insurance Feasibility Study” was published in 1978.

By 1980 the traditional medical audit had become a dinosaur in the world of quality assessment and assurance in favor of a problem-focused method.

Early KP physicians collaborate on a hospital patient's diagnosis and treatment. KP photo

Review organizations move away from medical audits

In 1980 JCAH quietly abandoned the traditional medical records audit. JCAH’s new published standards required hospitals to have a documented quality assurance program but no specific audit program was mandated. Members of the federal Professional Services Review Organizations (PSROs), local agencies designated by Medicare and Medicaid to study quality of care, were also disappointed by the medical audit results and phased out the method.

In its 10th anniversary issue in 1984, the JCAH journal re-published Sapin’s 1980 groundbreaking article, “A Region-wide Quality of Care Monitoring and Problem Delineation Plan.” The article authored by Sapin, Gerald Borok, MPH, and Cheryl Tabatabal, rejected the traditional medical audit and described the problem-focused review scheme he and Rubin had developed and piloted.

In a 10-year anniversary reflective commentary, William C. Felch, MD, Quality Review Bulletin Editor and New York internist, recognized the new KP-generated system and touted the plan as “ambitious, carefully thought out and planned.”  He added: “The question five years later is how did it all work out?”

Next time: Birth of the National Committee for Quality Assurance

 

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Permanente physicians strive to prove high quality of care

posted on March 7, 2012

By Ginny McPartland
Heritage writer

T. Hart Baker, MD, medical director of the Southern California Permanente Medical Group, and William D. Finkle, Ph.D of the Economics and Statistics Department, review quality data. 1973 Kaiser Permanente Annual Report photo

Second in a series
By the late 1960s, Kaiser Permanente physicians were pretty confident about the quality of care they were providing the health plan’s growing membership. Although they were the target of unfair quality jabs by competing fee-for-service physicians, the Permanente Medical Groups in all regions had been validated in objective studies assessing medical care.

The National Advisory Commission on Health Manpower inspected KP operations and reviewed patient charts at program facilities in both California regions in 1967. The commission concluded: “The quality of care provided by Kaiser Permanente is equivalent, if not superior, to that available in most communities.”

Further validation came from a University of Michigan study of quality of care in Hawaii in 1969. Under the auspices of the Hawaii Medical Association, local specialists set up criteria for review of care. “The study indicated that care at Kaiser Foundation Hospital and by the Hawaii Permanente Medical Group were both substantially above the island (Oahu) average and among the best in the study,” B. L. Rhodes, MD, executive vice president and manager of operations, reported to the board of directors in 1983.

Despite praise, quality was becoming big issue

Such kudos didn’t really solve the quality issue for Kaiser Permanente. By the 1970s, it seemed as though every government agency, professional association and consumer group (and their brother and sister) wanted to get into the quality assurance game. This is where it started to get complicated.

“There was a quality frenzy in the 70s,” noted Sam Sapin, MD, an early Southern California Permanente physician and quality pioneer.

Kaiser Permanente physician at work. 1966 KP Annual Report photo

The year 1965 brought Medicare and Medicaid, programs enacted by Congress to provide medical care for the elderly and poor. Naturally the federal government, now pouring millions of dollars into health care for these populations, wanted a way to ensure the care was good.

This interest resulted in an amendment to the Social Security Act setting up Professional Standards and Review Organizations (PSROs) to monitor utilization and quality of care. Also in 1965, the Illinois Supreme Court ruled that hospitals are accountable for their doctors’ mistakes, a concept validated for California hospitals in subsequent court rulings.

In 1972, the California Medical Association (CMA), which accredited medical education programs, began requiring retrospective medical records audits to assess quality of care and to identify issues for continuing medical education programs.

The CMA adopted a medical audit system developed in 1956 by Paul Lembcke, MD, a New York quality evaluation pioneer and epidemiologist. The Lembcke method called for reviewers to select a topic arbitrarily and then review medical records of patients with that diagnosis after discharge from the hospital. Certain objective standards or criteria had replaced the subjective review by physicians.

Other agencies followed the CMA. The Joint Commission on the Accreditation of Hospitals (JCAH) adopted the same style of medical audit as a condition of accreditation. The American Hospital Association adopted a similar audit program. In 1973, the federal government widened its scope of quality review by including Lembcke-style medical audits as a requirement for designation as a qualified Health Maintenance Organization (HMO).

Honolulu KP physicians developed their own medical audit system in 1969. Here Clifford J. Straehley, MD, chief of surgery, right, and Raymond D. Stoneback, MD, chief of anesthesiology, discuss surgical audit data. 1973 KP Annual Report photo

Widely used and accepted medical audit falls out of favor

The medical audit adopted by everyone turned out to be wrongheaded, inefficient and expensive and was eventually abandoned. But during the 1970s, Kaiser Permanente had to perform such audits to keep its quality reputation intact.

“We all followed the Pied Piper,” Sam Sapin offered in a talk to the KP board of directors in 1983. “The land was alive with auditing and auditors. A whole new profession of medical records analysts was created and millions and millions of dollars and countless hours were spent on auditing,” Sapin laments.

For the next almost 10 years, Sapin, in Southern California, and quality people in all KP regions would bow to the almighty medical audit, even though its effectiveness turned out to be a mirage. Sapin, appointed in 1972 as the first SCPMG director of Education and Research, lived and breathed quality audits. It was his job to set up a quality assurance program for all KP facilities in the south, a daunting charge.

KP regional quality reviews begin in 1973

Beginning in 1973, Sapin coordinated a quality assurance program with six KP Southern California hospital staffs who agreed on the same diagnosis to audit. Sapin and SCPMG medical director T. Hart Baker, MD, obtained a three-year federal government grant to conduct studies for the Experimental Medical Care Review Organization (EMCRO) program, which dovetailed perfectly with Sapin’s auditing efforts.

Baker, Sapin and others published SCPMG’s findings in “Quality of Medical Care: Research in Methods of Assessment and Assurance” in 1978. The EMCRO report detailed use of the Lembcke method and noted its flaws. Later, Sapin would judge the audit method too expensive for its value:

"The Human Touch" illustration appeared in the Kaiser Permanente 1968 Annual Report

“We subjected the medical audit model to rigorous study. We learned from these experiences, along with the rest of the country, that the audits we were instructed to do were not making any significant impact on the quality of care.”

Sapin also called out the difficulty in adopting criteria. “Physicians argued for hours about them, partly because most of the things we do to and for patients have never been scientifically validated. Every physician thinks he or she is doing the right thing in the right way and there is usually insufficient evidence to prove one right or wrong.”

Meanwhile, Leonard “Len” Rubin, MD, PhD, KP Northern California’s quality assurance leader, was developing an auditing method of his own. Joining KP in the 1950s, Rubin had a strong interest in quality measurement and began working in the late 1960s on an alternative to the mandated medical audit.

Sapin joined Rubin in his refining of a new audit methodology that would review patient care before discharge and only focus on identified problems.

Next time: Len Rubin’s less painful quality of care review process catches on with regulators.

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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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