Posts Tagged ‘Donald Berwick’

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:

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

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1990s begin with supercharged Kaiser Permanente quality agenda

posted on March 28, 2012

By Ginny McPartland
Heritage writer

Fifth in a series

Many KP physicians round out their experience with community service. Eimear Kennedy, MD, KP Georgia, volunteered for an AIDS clinical research project in Atlanta. 1988 Kaiser Permanente Annual Report photo

If the 1970s and 1980s brought a quality of care frenzy, circumstances in the 1990s conspired to create a veritable quality tsunami. Health care leaders reacted dramatically to a 1989 paper by industrial quality guru Donald Berwick and began to second guess health care reformers in Washington. Realizing their survival was at stake due to market pressures and government and employer demands for quality data, physicians and other health plan leaders dove head first into the quality quagmire.

Berwick’s message was revolutionary. His call to action was to take away the punitive side of quality review and bring all medical disciplines into a discussion of how to improve care processes and thus ensure better quality. Berwick’s influence was to abolish “The Theory of Bad Apples” in quality assurance and replace it with “The Theory of Continuous Improvement.”

Stepping Stones to Quality, cover of the KP employee magazine Spectrum, Summer 1991

Berwick, a physician in the Harvard Community Health Plan, had gotten his inspiration from Japanese industrial quality experts. Their carefully defined philosophy called “kaizen” led Japan to high quality factory production success. “An epigram captures this (Japanese) spirit: ‘Every defect is a treasure.’ In the discovery of imperfection lies the chance for processes to improve,” Berwick wrote in the New England Journal of Medicine Jan. 5, 1989 edition.

He adds: “Quality can be improved much more when people are assumed to be trying hard already, and are not accused of sloth. Fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to disaffection, distortion of information, and the loss of the chance to learn.”

Flawless care requires support for decisions

Physicians rely on a support system to carry out high quality health care, Berwick noted. “Flawless care requires not just sound decisions but also sound supports for those decisions . . . In hospitals, physicians both rely on and help shape almost every process pertaining to patients’ experiences, from support services, such as dietary and housekeeping, to clinical care services, such as laboratories and nursing. Few (processes) can improve without the help of the medical staff.”

Cover of the Quality Agenda in Action, 1992

Berwick urged significant investment in assessing and improving quality of care. “In other industries, quality improvement has yielded high dividends in cost reductions that may occur in health care as well. . . The most important investments of all are in education and study, to understand the complex production processes used in health care; we must understand them before we can improve them.”

With Berwick’s message ringing in their ears, Kaiser Permanente leaders jumped into high gear. In September of 1990, the Kaiser Permanente Committee embraced Berwick’s bold new approach, which had been dubbed “TQM,” for Total Quality Management. At the same time, the Joint Commission on Accreditation of Hospitals also adopted TQM principles in its reviews.

Vohs and Lawrence put force behind the Quality Agenda

In 1991, Jim Vohs, chairman of the board, and David Lawrence, MD, vice chairman and CEO, launched the Quality Agenda, an ambitious, all encompassing plan of attack to improve quality across all KP regions, involving all levels of the organization.

The 1991 Annual Report, titled the Quest for Quality, was devoted to chronicling the TQM phenomenon and explaining its genesis and hope for the future. The report acknowledged the work done previously by pioneers Sam Sapin, MD, and Leonard Rubin, MD, but declared the need to step it up:

KP Quality Agenda graphic emphasizing improvement as a key step in the quality assurance process, 1992

“The role of quality assurance historically has been to identify problems within the system,” explained Susan Leary, director of quality assurance in the Program Office. “But with TQM,” she says, “we’re given new empowerment to go out and get involved in the planning process and to make system-wide changes once those problems are identified.”

A 53-page binder produced at the launch of the Quality Agenda defined the campaign as “A Roadmap for the Future.”  The guide was to speed up KP quality improvement efforts and to intensify efforts to share good ideas and innovations across the regions.

The campaign emphasized the need to get all employees to understand and take part in quality initiatives. The roadmap outlined five specific tasks: 1) creating of a positive work environment; 2) measuring what we do; 3) improving what we do; 4) developing new approaches; and 5) telling our story.

KP’s first program-wide Total Quality Management conference

In 1992, the first annual interregional conference on Total Quality Management featured workshops conducted by Don Berwick, MD; Brent James, MD, renowned quality improvement expert and statistician of Intermountain Healthcare in Utah; and David Eddy, MD, the man who invented the computer model that could compile a wide range of health data and simulate a realistic clinical situation.

Article in 1991 Spectrum magazine about David Eddy, MD, hired by KP to help discover which treatments would have the best outcomes.

Eddy was hired by the Southern California Permanente Medical Group in 1991 to use clinical research data to evaluate the benefits and harms of different clinical interventions. Eddy compiled actual patient outcomes and ascertained which treatment would likely bring the desired results.

“One treatment (for lower back pain) might have a 30 percent chance of returning a patient to work, while another has only a 10 percent chance,” Eddy said. “But the first treatment might have greater risks. How do we decide if the greatest benefits of the first treatment are worth the risk? To determine this, we’d like to ask patients what they prefer. They’re the ones who will live or die by these decisions.”

Physicians need help synthesizing complex medical research

From his research, Eddy set up a system to develop clinical guidelines or best practices to help physicians with decision making. “It’s simply unrealistic to think individuals can synthesize in their heads scores of pieces of evidence, accurately estimate the outcomes of different options, and judge the desirability of those outcomes for patients,” Eddy wrote in a 1990 article for the Journal of the American Medical Association.

In 1993, Lawrence published the Quality Agenda in Action, a report on quality initiatives across the program. Highlights included KP’s work with HMO groups and six large employers to develop the HEDIS (Health Employer Data and Information Set) quality measures and specific data collection methodologies for various treatments and preventive screenings.

"How we're learning from each other" was the theme of the Spring 1992 Spectrum magazine.

The update also called out the Northern California Permanente Medical Group for its own launch of a program to establish best practices, vetted through research, and to implement and evaluate them. The Interregional Nursing Task Force brought together nurses from all regions to set up a system of best nursing practices.

A five-year study conducted by Southern California concluded that normal childbirth after a Caesarean section was possible and safe; while another study of 2.5 million patients in Northern California showed that screening for rectum and distal colon cancer with sigmoidoscopy decreased the rate of death from these conditions by 60 to 75 percent. In all, more than 350 TQM projects had been launched across KP’s 12 regions in the four years prior to the publication of Lawrence’s report.

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

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