, Heritage writer
Over the past year, dedicated professionals across the Kaiser Permanente have taken steps to position the organization as a destination employer for veterans. Kaiser Permanente’s goal is to ensure it provides a supportive and inclusive environment for all individuals within its current and future workforce, including those with military backgrounds.
But for a health plan born in the crucible of the last world war, support for those who served is not a new idea.
On October 17, 1944 – less than a year before the war neared its end – Henry J. Kaiser addressed an audience at the Herald Tribune Forum in the Waldorf-Astoria Hotel, New York City. The topic? Jobs for all.
On this one fact, there is unanimous agreement: every man in the American Forces has the right to come home not only to a job, but to peace. Anything less would be a denial of the true American way of life. Peace means so much more than a cessation of hostilities! Peace is a state of mind. It is based on the sense of security. There can be no peace in the individual soul, unless there is peace in the souls of all with whom we must live and work. Jobs for all could well be the first slogan for a just and lasting peace.
…I have always believed that the future belongs to youth; it is theirs to build. Here is an opportunity to help youth see the pattern emerging out of a great surge of social forces. There must be purpose in the cause to which a whole generation of youth is giving their lives.
Often I am classified as a dreamer, particularly when I talk about health insurance. To live abundantly and take part in a productive economy, our people must have health. This is not only a matter of medical science, but of facilities. Health service can be rendered on a self-sustaining insurance basis, at a price well within the reach of all. The cost of such medical care might be incorporated in the monthly payments on the home, freeing the American family from the fear of illness and the loss of income!
We can go further and insure the payments when illness overtakes the head of the family. If American industry builds and equips modern hospitals in one thousand American communities in the first year after the war, prepaid medical service could then be organized around these facilities. The five hundred million dollars so spent will generate employment for two hundred and fifty thousand workers. I am speaking from the experience of operating seven hospitals on this basis. It is encouraging to read recent announcements that public health authorities are now thinking along these lines. Organized medicine is beginning to see the wisdom of this sound principle…
Remember, youth will not be handicapped by the prejudices or blindness of an outmoded past. The men and women who have accomplished the impossible in defense, in war, and in sustaining a war effort throughout the world, are not apt to be afraid. Our nation was created by men of faith, against obstacles such as you and I have never known. Our country is sustained by men of faith today in the midst of battle. There will be jobs for all if the men of faith have their way.
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By Ginny McPartland, Heritage writer
Model neighborhoods close to jobs and laid out with meandering lanes and few busy cross streets
Henry J. Kaiser and home builder Fritz Burns had a brilliant idea in the mid-1940s for encouraging people to use their feet for transportation. Kaiser and Burns were known at the time for their “model suburbs,” new neighborhoods that were laid out with winding lanes, rolling curbs, a minimum of busy intersections and space for schools, churches and stores.
Neither speed bumps nor other traffic-calming schemes were necessary on meandering streets where children rode their one-speed bikes and played football and kick-the-can without fear of a fast car running them over.
To meet a severe housing shortage at the end of World War II, Henry Kaiser, who had pioneered streamlined production methods to turn out cargo ships in record time, saw another opportunity to innovate and mass produce. Home construction had slowed way down during the war, and the population was beginning to soar.
Housing boom fed by GI Bill and FHA
Returning servicemen and women were settling and contributing to the baby boom, and financing provided by the GI Bill and the Federal Housing Administration fueled the surge in demand for new, affordable houses.
Kaiser hooked up with Burns and launched Kaiser Community Homes. The company embraced the Federal Housing Administration standards to develop thousands of low-priced homes for the common man. They built minimal tract residences of about 1,000 square feet on the periphery of urban areas in close proximity to industries that employed many workers.
Burns and his Northern California counterpart David Bohannan argued for streamlined transit:
“Transportation to business areas should be rapid and direct, and when possible, jobs should be within walking distance,” Burns and Bohannan wrote in “Postwar Housing,” a state of California booklet published in 1945.
Panorama City, Kaiser Community Homes’ largest development, incorporated these principles, and Los Angeles regional planning professionals touted the development of the Panorama Dairy Ranch in the city’s “Accomplishments 1945.”
Kaiser-Burns plan Panorama City in San Fernando Valley
With 3,000 homes built between 1947 and 1952, Panorama City was the first large postwar community in the San Fernando Valley. In making up the blueprint for the community, Kaiser engineers also designated space for a Kaiser Permanente clinic and hospital, which was completed in 1962.
A General Motors plant completed in 1947 was situated one quarter mile south of Roscoe Boulevard, the southern boundary of Panorama City. A Schlitz Brewery sat immediately to the east, and Lockheed and Vega Aircraft, and Precision Tool, were all within seven miles of the Kaiser development.
Kaiser and Burns sought land that was adjacent to manufacturing to fulfill their aim of building “a city where a city belongs,” wrote Greg Hise in his book titled “Magnetic Los Angeles,” published in 1997 by Johns Hopkins University Press.
Their intent was to create a regional city just outside of Los Angeles that would be self-contained and buffered from urban life. Farm lands, still flourishing with dairy cows and chickens, were to provide a buffer for the happily hemmed-in microcosm.
General Motors plant to catch up with demand
The new Van Nuys GM plant near Panorama City (closed in 1992) initially employed 1,500 workers to turn out 100,000 new Chevrolet models to catch up with Southern Californians’ demands.
Kaiser Community Homes, David Bohannon and others also built “ideal” suburbs in the Northern California communities of San Leandro, San Lorenzo and San Jose where Chrysler, Ford and GM were expanding their manufacturing capacity.
Ironically, the industry that drove the creation and growth of Panorama City and other auto manufacturing areas was the eventual undoing of the pedestrian-friendly landscape. With auto ownership on the rise, transit ridership declined steadily.
“The geographical spread and low population densities of the postwar suburbs . . . made transit impractical for most people living outside the older and denser urban areas,” a 2011 California Department of Transportation report stated.
Automobile use surpasses other transit modes
By 1956, more than 54 million Americans were driving automobiles. By the end of the 1950s, 95 percent of all trips in Los Angeles were by private vehicle.
As a consequence, regional planners seemed to lose control of suburban sprawl in the 1950s and subsequent decades. Hise writes: “Regardless of how well (communities) were planned internally . . . they overwhelmed the (San Fernando) valley, as well as outer zones of other American cities.”
The erosion of suburban Americans’ opportunities to reach daily destinations on foot and the consequent decline in fitness has spawned such programs as Kaiser Permanente’s “Every Body Walk!” The campaign encourages people to walk whenever possible – leave the car in the garage for short trips to the market or elsewhere, take the stairs instead of the elevator, and walk for fun and fresh air every day.
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By Ginny McPartland
Last in a series
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.
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. 2 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, 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
By Laura Thomas
First of two articles
When the winner of Kaiser Permanente’s “Small Hospital, Big Idea” design contest is announced in February, at first glance it may appear the 65-year-old health plan is taking a major turn off the road it followed for decades: building large hospitals as hubs for satellite medical clinics in surrounding communities.
In the competition, architects have been asked to dream up a model for a community health center with many of the features of a larger KP hospital, including surgery, emergency, laboratory, and pharmacy. The small hospital will leverage the newest diagnostic, treatment, and communications tools for outpatient and inpatient basic and acute care — all in one cutting edge hospital.
The key for planners is to find a set of design concepts that will balance the latest in technology with a humanistic approach in providing efficient, affordable, and high quality care. The “hospital” will create a place to encourage and nurture a healthy lifestyle for KP’s members and the community at large.
The winning design will be used to wildly modernize and perfect the self-sufficient hospital design pioneered by Garfield on construction sites in the Southern California desert and the Grand Coulee Dam in Washington State in the 1930s and 1940s.
The plans, promising to be ingenious, will be the blueprint for construction of the “best of the best” small KP hospital, likely to be built in the High Desert northeast of Los Angeles. Rather than being a major departure from tradition, the Small Hospital, Big Idea concept will bring the medical plan’s legacy of hospital building full circle.
Ironically, the setting for the early Garfield hospital designs, as well as the imminent creation of the KP futuristic “Big Idea” small hospital, was and is the Southern California Mojave Desert.
Ingenious health care for Garfield’s time
Garfield’s ability to keep 11,000 Los Angeles Aqueduct workers healthy improved greatly as the men came in for routine checkups instead of waiting until they were really sick. His other initial foray into prevention was direct: To reduce head injuries and nail punctures, he went to the job sites and lectured the workers about pounding down nails and then inspected tunnels for dangerous shoring.
Garfield eventually built three hospitals in the desert, equipping them with air conditioning — the latest technology — and newly invented venetian blinds. He furnished the wards with soothing color schemes, flower containers, and personal radios to elevate patients’ moods.
Garfield’s three hospitals were far flung — the first at Desert Center, another at the east end of the aqueduct at Parker Dam, and the third at the Imperial Dam near Yuma, Arizona. He staffed each with a physician, and he zipped back and forth by car across 100-mile stretches of desert to perform surgery.
Garfield’s next project was to refurbish and outfit a rundown 35-bed facility for Henry Kaiser’s workers on the Grand Coulee Dam project in Mason City, Washington. The union was excited when Garfield promised air conditioning, but Kaiser’s son Edgar, who was running the project, said no. (Garfield installed it anyway, paying for it out of his pocket; a slightly annoyed Kaiser reimbursed him).
That small hospital, with its early team of group practice doctors, went full bore into preventive care for the 15,000 residents (workers and their families) in the company town.
“They saw simple acute appendicitis instead of peritonitis; earaches instead of mastoiditis; upper respiratory infections and less pneumonia; early lumps in the breast instead of metastatic carcinoma,” writes Dr. John Smillie in his history of the Permanente Medical Group. “The Coulee physicians were capable of handling just about any case that came their way, including serious cancer surgeries. Only one patient, a suspected brain tumor, had to be referred to Spokane.”
They also established a satellite community service: Millie Cutting, a nurse and wife of job site physician Cecil Cutting, solicited funds door-to-door — and received generous contributions from the brothel madams — to set up a well baby clinic in a local church.
Bigger challenges on the Home Front
The urgent need for quality health care for Kaiser West Coast Shipyards workers during World War II dictated the facilities Henry Kaiser and Sidney Garfield could establish for their often sick, weak, and injured patients. The Richmond Field Hospital, later serving the community at large, was thrown up in a hurry and opened with 10 beds in August of 1942.
Garfield carefully designed the modern 70-bed Oakland Medical Center, although it was the hurried resurrection of the surviving maternity wing of the Victorian Fabiola hospital, which had been torn down years before. The Oakland hospital, also opening in August of 1942, expanded twice (to 145 beds) before the end of the war and its successor structures remain the hub of East Bay facilities to this day.
With World War II behind him and the Kaiser Permanente medical plan beginning to grow, Sidney Garfield was able to experiment with various ways of using architecture and design to improve both the efficiency of staff and services and patient comfort as well. In the early 1950s, Garfield, whose boyhood dream was to become an architect, designed his first two large “dream” hospitals in San Francisco and Los Angeles and his last two “small city” hospitals in Walnut Creek and Fontana.
Innovative, efficient mid-century designs
He designed them all around principles he held dear: efficiency, economy, and patient comfort. Renowned architect Clarence Mayhew designed Walnut Creek and Fontana to echo the mid-century desire to have the indoors and the outdoors meld. Each was Y-shaped with two wings of rooms that opened to the natural environment to both soothe the patient and give visitors access while nurses, doctors, and orderlies circulated freely down an interior corridor.
Despite being small, they incorporated the features of the larger hospitals. The central work area was abolished in favor of stations distributed along the corridor so each nurse would be a few steps from her patients with records and supplies shelved nearby.
And the mostly private patient rooms were equipped with all manner of modern convenience with power-drawn curtains and bed adjustments operated by push buttons, a built-in lavatory, toilet, closets, oxygen outlet, plus phonograph outlet and radio.
Garfield received national attention for his rooming-in maternity section where babies were kept close to their mothers, but also within reach of the nurses through a bassinet that slid between the room and nursery.
Architectural Forum magazine in July 1954 lauded all the new technology and design innovations in Walnut Creek: “For all its luxuries, care at Walnut Creek actually costs less than at older hospitals. The gadgets speed recuperation and encourage patients to care for their own minor needs.” Thus, the nurses’ time spent as errand girls would be reduced. He was a great believer in the power of human contact in the healing process.
Garfield said in the KP Reporter in 1963, “Over the years, we have been working for development of functional design in hospitals in which our staffs can serve patients with a minimum of wasted time and energy. They will then have more time to be with patients, and this human contact makes for happier patients, more stimulus to recovery.”
View a 1953 video about the Kaiser Permanente “dream” hospitals.DreamHospital
Next time: Kaiser Permanente member growth spurs new thinking on how to create the ultimate patient experience.