Editor’s note: Kaiser Permanente physician and educator Martin Shearn and his wife Lori traveled to Brazil in 1973 where Dr. Shearn served as chief of staff for the SS Hope hospital ship docked in Maceio, a poor coastal community in Northeast Brazil.
, Guest writer
Fourth in a series
Before Project Hope, outpatient clinics didn’t exist in Maceio. The mother-baby clinic set up by Hope (in 1973) was a miracle. Ordinary people in this community had no health care at all, and no place to go for vaccinations or health information.
In a poor area where no care facility had existed, Hope staff found an old wooden building to serve as a clinic for new mothers whose babies were not thriving. There, a group of local women were trained to act as educators. They were gathered from the community and carefully screened, mostly for their willingness to learn and to work hard.
The women were shown what happens on their hands when they are not washed properly and germs are allowed to grow. They were shown graphically that flies contaminate food and open sores and that it’s necessary to keep wounds sterile.
The “nurses” became the health educators of their community, explaining to mothers the risks of putting a pacifier back in the baby’s mouth after it has fallen to the dirty floor. They were amazed at how many diseases can be prevented by vaccination and inoculation.
Many of the children were suffering from a type of malnutrition called kwashiorkor that occurs when there’s not enough protein in the diet. One of the symptoms is a protruding belly.
The mothers learned about better nutrition and how creatures like mollusks and snails in the waters surrounding them could provide the protein their children needed. The mothers were instructed how to prepare the food and the babies magically began to thrive.
Half-built structure converted to outpatient clinic
The crowning achievement of the Hope mission to Maceio was the incredible discovery of a half-finished medical building and its conversion to an outpatient clinic. The project, meant to replace the inadequate and overcrowded community hospital, had been abandoned when federal funds ran out three years before we arrived.
When Hope staff toured the partially completed health care facility, the buildings were filthy and overgrown with mold and weeds. Amazingly, there were 75 finished rooms, beautifully tiled, and with a large dose of imagination and a grand push of energy, the university was convinced that this kernel of a new medical center could somehow be realized.
As soon as possible, Hope put the skeleton of a building into operation. It was cleaned and painted and equipment was gathered from supplies around town.
After the opening of this outpatient clinic, patients were assigned numbers, and if they couldn’t be seen one day, they could come back the next. A patient’s problem was evaluated by a doctor who decided whether or not the patient should be admitted, treated in the clinic or sent home.
Parents brought their children to see the doctor, even though they had never had such an experience before. They were taught how much they themselves could improve their own well-being even without additional money, using only the tools readily available.
Even though changes came very slowly, the Maceio community responded, and progress could be seen. When their prescriptions for various ailments ran out, the patient loads suddenly increased and they lined up around the block to see the doctor.
One of the diseases the Hope staff treated was Chagas, an infection found in Latin America that is spread by a parasite called a kissing bug. Dr. Shearn was inspired to write a poem about the disease and it was published in the “Annals of Internal Medicine” in the October 1973 edition.
Thoughts on Chagas Disease
In Brazil there are regions with thousands of miles
Of jungles and swamplands and fierce crocodiles
There are boa constrictors of hideous mood
And piranhas who look upon humans as food
But passions exist here quite different from fright
Abetted by kissing bugs active at night
The sleeper is sought and the kiss is bestowed
Then the insect retreats to its nightly abode
The encounter is brief but it quickly erects
A subtle arrangement with complex effects
The seal of that union is destined to start
A lasting relationship deep in the heart
The clinic continued after the ship left. The auxiliaries who became the nurses at this clinic were carefully trained to read numbers, to take temperatures, to read scales for weighing babies. They also gave shots and inserted IVs when necessary. They were carefully supervised until they were able to function confidently alone.
Hope’s success was not lost on our Brazilian hosts. The new clinic opened with great fanfare and heavy local and national publicity.
Hope made a big difference in improving the health of this community.
Editor’s note: Dr. Martin Shearn, who passed away in 2002 after many years as a Permanente physician, added to Lori’s insights in a letter to friends dated Sept. 10, 1973:
“The work has been the most interesting and worthwhile that I’ve done. The program has come along well. The level of education has risen measurably and concepts have been accepted. We are introducing a Kaiser-type ambulatory (care) replete with multiphasic type screening for the indigent.
“The new ambulatory structure started several years ago will be ready for occupancy next month so we will have a little time to work there before we leave.
There will be a relatively large (30 people) land-based program left behind that will include among others a medical director, biostatistician, and epidemiologist. Should be able to define the population with respect to health, get some patient profiles, decent medical records and get busy with vaccinations, nutritional advice and medical care.”
Next time: Children suffering years with birth defects get lifesaving surgery aboard SS Hope.
By Ginny McPartland, Heritage writer
Shipyard physician achieves brilliant postwar career as international reproductive biology expert
Before 1943, nobody knew how well women shipyard workers would adapt to the grit and physicality of a man’s world of heavy industry. In the midst of World War II, physician Hannah Peters tackled the job of unraveling that mystery without a play book.
She cared for female workers that poured into the Kaiser Richmond Shipyards. These women were pioneers, recruited to industry for the first time due to the war emergency.
Peters, German-born and trained in New York, had migrated to California in 1940 and set up an office in East Oakland. She found herself struggling to make ends meet and realized she needed to find a way to connect with patients who needed her.
When the United States entered the war in late 1941, Peters heard about Sidney Garfield, MD, who was developing a medical care program for Henry Kaiser’s shipyard workers in Richmond, Calif. She decided to leave private practice and join the staff of the Permanente Health Plan.
Shipyard women craved special attention
She quickly learned that the needs of women workers were abundant. They came from the South, the Midwest and the East Coast, and many had never seen a physician.
“I joined the medical department but it soon became clear to me that a gynecological department was necessary to take care of the special problems of the 23,000 women working in the yards,” Peters wrote in her memoir years later.
“A trained gynecologist was added to the staff and we established special programs to deal with the question of abnormal menstruation, pregnancy, venereal disease, sexual problems and to provide contraceptive services,” Peters wrote.
In seeing her patients, Peters noted many complaints about excessive menstrual bleeding that began when they started doing heavy work. Peters deduced that with a change in diet, to incorporate more carbohydrates for work energy, the women were worsening an already existing Vitamin B deficiency. She found shots of Vitamin B-complex solved the problem in most cases.
Peters also noticed that women lacked the stamina and strength to comfortably do their jobs. She arranged an activity program that had the Rosies (the term used to describe women war workers) climbing ladders and performing other tasks meant to strengthen their bodies to better handle their jobs.
Female workers screened for cancer
A believer in prenatal care and cancer prevention screening, Peters encouraged women to seek care often. She also urged women to come to the clinic to have pelvic and breast examinations every six months to screen for cancer of the ovaries, cervix, uterus and breast.
“In this way (conducting frequent physical examinations) we have demonstrated that extremely early cancer of the cervix can be consistently detected and not stumbled upon accidentally,” Peters and colleague Wilson Footer, MD, wrote in their article “Gynecology in Industry,” published in the Permanente Foundation Medical Bulletin and elsewhere in 1945.
The physicians also distributed materials to educate workers on how to avoid venereal disease and unwanted pregnancy. In their study, Peters and Footer also looked at the question of whether women should continue to work after they become pregnant.
In reviewing many cases of miscarriage among yard workers over a two-year period, they concluded that none of the terminations could be blamed on the work.
Shipyard experience opens up opportunities
“(Later in the war) another obstetrician (Dr. Robert W. King, a prince of a fellow) joined our group. He taught me obstetrics and gynecological surgery. . . I learned a great deal during the three years I was at Permanente . . . the years working with the shipyard women gave me experiences I could not have gotten in a life-time of private practice.
“The work with so many women of different backgrounds and coming from different cultures opened a new field for me: office gynecology,” she wrote.
After the war, Peters continued her work in women’s health, including family planning in India and elsewhere. She distinguished herself over the decades as a prolific publisher of research about reproductive biology and cancer.
She founded the Laboratory of Reproductive Health in Copenhagen, Denmark, in 1959 and headed the lab until her retirement in 1980. Hannah Peters passed away in 2009 at the age of 97.
By Ginny McPartland, Heritage writer
Kaiser Permanente founding physician Sidney Garfield caught on early that changing people’s habits would have positive results for their health. Urging his patients to avoid accidents by following safety guidelines and eating right to avoid health problems was a no-brainer for Garfield. Everyone would be happier and healthier, and the need for costly medical care could be minimized.
Voila! Prepaid care with an emphasis on prevention. Garfield adopted this theme in 1933, and Kaiser Permanente leaders have held this as a predominant tenet ever since.
Garfield’s interest in nutrition and exercise programs for shipyard workers in the 1940s, multiphasic examinations (annual physicals) in the 1950s, data processing of patient records in the 1960s, health education centers in the 1970s and the Total Health Project in the 1980s all fed into the push to promote healthy lifestyles and prevent illness.
Newsletters in the World War II Kaiser shipyards constantly reminded workers to eat three square meals a day and avoid too much fat and sugar. “Are you starving?” one article asked. “You can be starved without being hungry. . . Are you aware: 24 million man-hours per month (nationally) are lost through minor illnesses preventable by better nutrition?”
The Kaiser child care centers served healthy meals, and parents could buy nutritious family dinners to take home when they collected their offspring at the end of the day. Shipyard management sponsored intramural sports teams to help workers blow off steam and stay fit.
Screening workers for unhealthy habits
In 1950 Dr. Garfield responded to labor leader Harry Bridges’ request for a preventive care screening program for the members of his longshoremen’s and warehousemen’s union. The examinations, union-mandated for all workers, highlighted lifestyle problems and educated the men on how to avoid heart disease and other chronic illness.
In the 1960s, the first computer technology recorded the examination results so physicians could track their patients’ progress electronically and identify trends that could aid in the care and treatment of other patients, even in subsequent decades.
The 1970s saw the debut of the health education centers in which patients could seek disease prevention information and partake in groundbreaking programs to help them maintain healthy lifestyles and a healthy weight. (This was the beginning of Kaiser Permanente’s Healthy Living centers that offer a myriad of programs designed to preserve good physical and mental health and help patients manage chronic conditions.)
Health appraisal gains momentum
Health appraisal programs were established in a number of Kaiser Permanente locations, and healthy members were encouraged to visit the clinic when they were well, not just when illness struck. They filled out questionnaires and discussed their health status with practitioners who tracked their lifestyles and gave advice on staying well.
In the 1980s, Dr. Garfield conducted the Total Health research project in which he expanded the health assessment theme and had new well members diverted to a Total Health Center in which the emphasis was on promoting healthy lifestyles.
In the 1990s, Kaiser Permanente researchers participated in studies to test the success of a dietary regimen meant to reduce blood pressure and help prevent heart attacks and strokes. The Dietary Approaches to Stop Hypertension approach called for a healthy diet rich in fruits, vegetables, whole grains, low-fat dairy, fish, poultry and nuts.
The participants who followed DASH experienced a significant reduction in 24-hour blood pressure. The others, who continued to eat red meat, sweets and sugary soda, saw no improvement in blood pressure. Following the study, the DASH approach became the basis of Kaiser Permanente’s teaching about the prevention of hypertension and related conditions.
Also in the 1990s, Kaiser Permanente physician Vincent Felitti discovered while running a health appraisal clinic in the San Diego area that some patients needed help overcoming childhood trauma before they could change unhealthy behavior. Felitti conducted the Adverse Childhood Experience study and urged the consideration of psychological as well as physical issues in assessing a patient’s ability to adopt a healthy lifestyle.
Thriving in the 21st century
In 2004 Kaiser Permanente launched its Thrive advertising campaign, which spotlighted the health plan’s continuing emphasis on healthy living to help patients stay well. In the 20-Teens, the organization gave birth to other behavior change modalities, including online healthy lifestyle programs, Healthy Eating and Active Living community programs and free classes open to the public.
In 2012, Kaiser Permanente launched “Every Body Walk!” a campaign to get literally everyone up on their feet to take the first small steps that can lead to success in achieving a healthy lifestyle.
Today, patients who choose to alter their habits to achieve better health can get help in Kaiser Permanente’s Healthy Living classes, by enrolling in online Healthy Lifestyle programs, and by accessing the bonanza of health information on kaiserpermanente.org.
By Lincoln Cushing, Heritage writer
One of the major academic figures in American public health was Lester Breslow, MD, who passed away last year at the age of 97. Dr. Breslow was a former dean of the Fielding School of Public Health at UCLA and director of the California Department of Public Health from 1965-1968.
He was also president of the American Public Health Association from 1968 to 1969. Central to Dr. Breslow’s research was mathematical support for the premise that improving personal habits such as reducing smoking, eating better, and sleeping well could have a significant impact on life longevity and quality.
Dr. Breslow was also a pioneer in multiphasic screening and an advocate for the Automated Multiphasic Health Test developed by Kaiser Permanente’s Morris Collen, MD, an early medical informatics guru who turns 100 this November.
National Public Health Week, April 1-7, is a good time to revisit Kaiser Permanente’s role in the early recognition of preventive care as a way to address public health issues.
Breslow had developed the original multiphasic screening (the examination of large numbers of people with a series of tests for detecting diseases) during the 1940s, and Collen improved upon it with new technology. The first beneficiaries of Collen’s multiphasic process were members of the International Longshoremen’s and Warehousemen’s Union in 1951.
The AMHT was a battery of tests, administered in an efficient routine by medical professionals and supported by then-new mechanical and chemical analytic devices. The results were funneled into a powerful mainframe computer.
From a public health perspective, the ability to efficiently diagnose communicable and noncommunicable diseases not only benefitted the individual patient, it also helped to stem public health risks as well.
In Breslow’s 1973 Preventive Medicine article, “An Historical Review of Multiphasic Screening,” he noted: “Automated multiphasic screening opens the possibility of extending the health-maintenance type of health care to all groups of the population, particularly including those most likely to suffer from the conditions now responsible for the greatest amount of disability and death.”
Dr. Collen taught two semesters at UC Berkeley’s School of Public Health during the spring and fall of 1965; much of the curriculum explored the uses of multiphasic exams. Students included physicians engaged in their continuing medical education.
Final papers for the classes included such subjects as “Evaluation of Environmental Toxins Utilizing Automated Methods” by David R. Brown, “Obesity and its Measurements as it Relates to a Multiphasic Screening Program” by Clarence F. Watson, MD, and “Biological Effects of Magnetic Fields” by Earl F. White.
Although the multiphasic screening as it was developed in the 1960s has been replaced by other diagnostic methods, the efficient application of medical diagnostic tools – and the enormous Kaiser Permanente patient database that has accumulated over the years – continues to advance public health.
Also see: “Screening for Better Health: Medical Care as a Right”
By Lincoln Cushing, Heritage writer
In 1930s America, manual labor of all types– farming, construction, and manufacturing – was dangerous. In those depressed and troubled times, anxious workers were glad to have a job despite the risk of injury or death. Statistics of the decade told the story: workers were killed at an annual rate of 37 per 100,000 employees.
It was in this environment that Sidney R. Garfield began to offer industrial medical care for some of the 5,000 men working on the Colorado River Aqueduct Project in 1933. Garfield addressed the problem head-on by encouraging safe work habits and identifying and eliminating hazards. Garfield, bent on keeping the workers well, actively nurtured a culture of safety awareness and accident prevention.
Garfield’s vigilance to ensure a safe workplace – key to his early preventive care philosophy – remains a vital part of the Kaiser Permanente Health Plan he started with Henry Kaiser almost 70 years ago.
Garfield and Kaiser found synergy in providing health care for Kaiser’s 8,000 workers at the Grand Coulee Dam project in Washington state starting in 1938. That was practice for the real test they faced in maintaining the health of shipyard workers during World War II.
No time to plan for war industries
With almost no time for preparation or planning, Kaiser hired almost 200,000 new employees to toil nonstop to support American and Allied war efforts. Henry Kaiser ran seven West Coast shipyards and a steel mill in Fontana, Calif. His workforce was not composed of the usual sturdy males with experience in the trades – those men were serving in the military. Most shipyard workers were migrants from the South and Midwest, and about a third of them were women. Many were disabled. Few had held industrial jobs before.
The Kaiser Shipyards managers instituted several measures to reduce workplace risk.
One approach was to take care to assign people to the right job when they were first hired. In early 1944, the War Manpower Commission contracted with Permanente Foundation Hospitals to compile data about the physical requirements of each job in the shipyard. This study resulted in a 627-page reference guide called the Physical Demands and Capacities Analysis.
After workers were hired, they were not placed in a job until managers could fully understand their physical capabilities. The job placement guide helped avoid assigning someone to a job they couldn’t physically handle.
The “Plate Acetylene Burner” job description in the guide reads: “Climbs 6 steps to and from assembly platform twice daily, and walks within 500’ x 65’ area to stand, stoop, reach down, grasp, lift, and carry up to 35 pounds of “burning” equipment (women), and up to 75 pounds (men) to place where burning is to be done (25% of job).”
An article in the June 1, 1944, San Francisco Call Bulletin noted the study’s long-term importance. The manpower commission’s regional director told the paper: “The technique (methodology) on which (the research) is based will be invaluable in the postwar period when thousands of returning service men and women will have to be fitted into new jobs.”
Another strategy was to conduct ongoing worker education about occupational hazards. The weekly shipyard newsletters regularly featured cartoons, articles, contests, and photos about the right and wrong way to perform any task. The Richmond newsletter Fore ‘n’ Aft published a “Safety Boner Contest” cartoon created in the nearby Marinship yard (Sausalito) asking readers to identify hazards. Although 112 errors were intentionally drawn in, a zealous reader in a Vancouver (Washington) yard found 118.
Changes in law, technology curb hazards
Death and injury from industrial hazards such as coal dust, explosions, and asbestos have declined markedly in the past century, partly due to changing modes of production and partly due to progressive legislation.
One key step was the enactment of the Occupational Safety and Health Act in 1970, which helped accelerate an already improving work environment. In the 22-year period prior to OSHA’s existence, death rates dropped by 38 percent from the 1948 rate; in the first 22 years following its creation rates dropped by more than 61 percent.[i]
Hazards change. The most significant workplace health problem emerging in the late 20th century was the array of musculoskeletal disorders caused by repetitive stress. And today, in the health care field, other dangers lurk, such as needle sticks, exposure to contaminated human fluids, and getting injured while repositioning and lifting patients.
LMP works for reduction of KP workplace injuries
With the 1997 birth of Kaiser Permanente’s Labor Management Partnership, worker safety programs took a huge leap forward. The LMP’s Workplace Safety Initiative, launched June 21, 2001, was the most comprehensive and ambitious effort to date, with a goal of reducing the number of workplace-related illnesses and injuries by 50 percent over the next four years.
“Too many people in our organization are being hurt on the job today,” said Dick Pettingill, then-president of the Kaiser Foundation Hospitals and Health Plan in California. “This is unacceptable to me, and it should be unacceptable to all of us.”[ii]
The next year newly appointed KP Chairman and CEO George Halvorson and AFL-CIO President John Sweeney called on employees, managers, and physicians nationwide to make their workplaces safer. “There is no reason why we should accept an environment in which accidents are occurring,” Halvorson said. “We’re all going to work together, in Partnership teams, to improve the safety of our workplace.”[iii]
Hundreds of trained two-person teams from labor and management toured medical centers and regional operations facilities in “Broad Engagement Walk-throughs” sponsored by Southern California Region’s Workplace Safety group. The teams talked to unit staff who also responded to surveys to help identify workplace safety issues.[iv]
KP HealthConnect® joins safety campaign
New technologies also demanded workplace safety planning. In 2004, the Kaiser Permanente HealthConnect® workplace safety team partnered with stakeholders in Northern California to minimize any negative ergonomic consequences of the new national electronic health record system. Equipment at 34,000 workstations and hundreds of nursing stations and exam rooms had been modified or replaced, so the workplace safety team developed customized carts, wall mounts, and other adjustments to make sure that the upgrades were safe for physicians and staff.[v]
One way the LMP plays a valuable role is through the site-specific unit-based teams and other natural clusters of workers with similar jobs. In 2004 the Los Angeles Medical Center’s Lift Teams (specially trained staff members who help nurses and physicians lift and move patients safely) reduced the number of workplace injuries by nearly 45 percent over a three-month period.[vi]
By the end of 2005, the Southern California injury rate had declined 29 percent – short of the 50 percent reduction goal but still a significant achievement. Northern California met its goal of 50 percent reduction one year later.
Another major effort is the KP Workplace Safety Program, which seeks to reduce injury on the job for all employees of Kaiser Permanente, from office workers to nurses to couriers. Planning and implementation is coordinated by a national leadership team with regional representation.
In Northern California, the WPS Program serves all represented employees, including those in non-LMP unions such as the California Nurses Association, Stationary Engineers Local 39, and the Guild for Professional Pharmacists.
The challenge continues. In 2011 Northern California WPS Program Executive Director Helen Archer-Duste, RN, MS, reiterated KP’s goal: “Working in health care is dangerous. I want to make us the safest place in health care . . . Our ultimate goal is to have a workplace with no injuries. I believe that can happen.”[vii]
Thanks to Kathy Gerwig (vice president, KP Employee Safety), Helen Archer-Duste (executive director, KP Workplace Safety and Care Experience), Patricia Hansen (KP regional workplace safety practice leader), and Maureen Anderson (Coalition of Kaiser Permanente Unions) for contributing to this article.
[ii]California Wire, “Workplace Safety Initiative: KP and Labor Partners Put Safety First,” Aug. 6, 2001.
[iii] California Wire, “U.S. Labor Leader, KP CEO, Employees, and Managers Launch Programwide LMP Workplace Safety Plans,” Nov. 4, 2002
[iv] California Wire, “Labor Management Partnership Reaches Staff in Workplace Safety ‘Walk-throughs’,” Nov. 11, 2002.
[v] California Wire, “Safety Is Key in KP HealthConnect® Deployment,” July 19, 2004.
[vi] California Wire, “Los Angeles Lift Team Wins LMP Award,” July 26, 2004.
[vii] “Workplace Injuries Plummet,” Inside KP, Nov. 8, 2011.
By Ginny McPartland
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.
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
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
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.”
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.’
“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.