Posts Tagged ‘NCQA’

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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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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Hawaii: Not your garden variety paradise

posted on October 7, 2010

By Ginny McPartland

To most outsiders, Hawaii is that far-off paradise where people go for that well-deserved rest and recreation. They come back tan and relaxed, and everyone is green with envy. To be sure, the Hawaiian Islands offer plenty for the casual visitor. But to the residents, it isn’t just about gargantuan waves and potent Mai Tai’s.

Hawaiians have to worry about the same things mainlanders worry about: a livelihood, a good future for their children, and quality health care. Lucky for them, taking good care of patients is top of mind for physicians in the Hawaii Permanente Medical Group. On a recent trip to Honolulu, I witnessed their determination first hand.

HPMG President Geoff Sewell MD and Heritage Director Tom Debley discuss KP history during a 50th anniversary event.

Although in a partying mood (they’re celebrating 50 years as a medical group in Hawaii), Permanente doctors focused on issues during a party/seminar in Honolulu. What have they done right in the past five decades? And what do they need to do differently – better – in the future?

Overcoming a tough situation

The Hawaii Permanente Medical Group staffed the second launching of Kaiser Permanente in Hawaii. In 1958, Henry J. Kaiser had built a 143-bed hospital in Waikiki and had hired a group of doctors who had other interests as well. In 1960, Kaiser realized that the doctors needed to serve the KP membership exclusively for the partnership to work. He then asked The Permanente Medical Group in California to help set up a new group.  Headed by Phillip Chu, MD, the reconfigured medical group began providing for Hawaii members in August of 1960. 

The 1960s was a difficult time for Permanente physicians, indeed for all group practice doctors. Across the country, traditional medical societies resisted prepaid group practice claiming it was “unethical” and denied patients choice of physicians. The hostile physicians denied hospital privileges and medical society membership to group practice physicians, and at times labeled the new care delivery method as “socialist” and its product “inferior.”

Undaunted, the Hawaii Permanente physicians persevered. They set out to prove their detractors wrong.  In 1969, the Hawaii region participated in a study conducted by the Hawaii Medical Association and the University of Michigan that showed KP hospital care to be above average in the state. Later, in 1977, the results of a University of Michigan quality of care study showed Hawaii Permanente Medical Group doctors to be well above the average among Hawaiian physicians. A total of 454 Oahu physicians in 18 specialties, including 42 Permanente physicians, participated in the study.

Quality a major focus

As early as 1969, the Hawaii region had established its own ongoing medical audit system. In 1971, the region received a federal grant to set up an experimental four-year program to monitor inpatient care. Later, Hawaii medical staff developed methods for monitoring outpatient care for all the Kaiser Permanente regions.

Not only was the Hawaii staff distinguishing itself in quality of care, but they were also participating in government programs to reach out and help the poor of its communities. The group participated in a federal Medicaid program in 1971 to care for 500 indigent families on Oahu and later expanded the program to Maui. Other community outreach programs followed.

Perhaps the ultimate community outreach program was launched in Hawaii last year when Kaiser Permanente started a high-tech mobile service on the Big Island. The 500-square-foot exam unit on wheels brings care and preventive screenings to thousands of KP members and to the uninsured in the community.  The van is equipped with digital mammography equipment and is connected to Kaiser Permanente’s comprehensive electronic health record system.

Doing fine now, thank you very much

Fifty years after its founding, Kaiser Permanente Hawaii is thriving. With 430 physicians, 4,400 employees, almost 224,000 members, 278 critical care hospital beds, and 17 outpatient clinics on three islands, the region has established itself as an organization bent on excellence and community service. In the past year, Kaiser Permanente Hawaii has received these designations:

— Highest-rated private health insurance plan in Hawaii (National Committee on Quality Assurance, NCQA, 2009)

–Number 1 Medicaid plan in the nation (US. News & World Report, 2010)

–Highest-rated health plan in the U.S. for breast cancer screening (NCQA, 2009)

–Highest accreditation rating of “excellence of quality and service (NCQA, 2009). Hawaii has earned this rating every year since the NCQA began rating health plans in 1999.

Henry J. Kaiser’s big Hawaii plans honored

View an early Hawaii KP patient could wake to.

Henry Kaiser’s flamboyant entrée into the Hawaii health care scene in 1958 eventually dovetailed beautifully into the Hawaii Permanente Medical Group’s plans. In celebrating its jubilee, the group staged a key event at the Hawaii Prince Hotel on Waikiki, the site of Kaiser’s first Hawaii hospital. Located adjacent to the Ala Wai Boat Harbor, Kaiser Permanente’s early patients awoke to beautiful tropical sunrises and drifted off to dramatic sunsets.

In 1986, the old hospital was blown up in a public spectacle that became part of an episode of the celebrated television series of the time, “Magnum, P. I.” starring Tom Selleck. The implosion made way for the new hotel, and Kaiser Permanente built a new, modern hospital on Moanalua Road north of Honolulu. This is the site of the Hawaii region Moanalua Medical Center and Clinic where construction is under way to expand and improve services.

Front view of the Hawaiian Village hotel built by Henry J. Kaiser in 1955

Meanwhile, just around the corner in Waikiki, Henry J. Kaiser had built his Kaiser Hawaiian Village, a uniquely designed resort that is now the Hilton Hawaiian Village. Kaiser showed his respect for the indigenous population by designing the villages to represent  the culture of the hotel’s surroundings. He employed Hawaiian Samoans to come to the resort site and hand-build the guest cottages. These craftsmen actually wove coconut fronds into thatching. To honor Henry Kaiser, the resort has created museum-like public displays telling the story of his Hawaiian feats.

Today, the Hilton resort also hosts the Bishop Museum Collection, a satellite museum that gives visitors a taste of the original Hawaii. The main Bishop Museum, recently restored and with a new science building, is the largest museum in the state and the premier natural and cultural history institution in the Pacific. The museum is located in Honolulu off the beaten tourist path.

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