, Heritage writer
What is the right way to reward creativity and hard work? What is an appropriate balance between corporate ownership and the public good? These issues form the root of copyright and patent law and have shifted over time and place.
Contrary to the practices of most major companies, however, Kaiser Permanente – and its earlier entity, Kaiser Industries – have long embraced the concept that sharing is not only good for the community, it’s responsible organizational practice.
On November 17, 1942, Henry J. Kaiser recommended that an independent federal agency be formed to license all new inventions and to distribute their benefits throughout industry.
His comments were published in many news outlets, including Billboard magazine’s December 1942 issue:
“Original ideas, suggestions and developments should be interchanged among allied industries, such as airplane (production) and shipbuilding and the steel industry,” Kaiser told a U.S. Senate military subcommittee studying technological mobilization.
He said he thought his position might be considered revolutionary, but added: “Industry will be more productive if patents are available to all industries able to use them. (After the war), compensation for their use should go to the individual as an incentive and not to the company that employs him (or her).”
Billboard’s article reported, “Workers in the Kaiser shipyards are encouraged to submit new ideas and techniques, and a prize is awarded each week for the best suggestion. In addition, the author of an accepted proposal works with an engineer in preparing sketches to illustrate an improved process.”
Kaiser told the committee that his industries made their data available to other builders, and likewise, he benefited from the findings of others.
Sharing tradition continues
That “revolutionary” position was not just a flash in the pan. Kaiser Permanente, Henry J. Kaiser’s most enduring legacy, has continued that tradition.
Kaiser Permanente’s fourth CEO, George Halvorson, who has led the organization since 2002, has long supported an open approach to innovation.
Some of these initiatives include:
The Care Connectivity Consortium includes Kaiser Permanente, the Mayo Clinic, Geisinger Health System of Pennsylvania, Intermountain Healthcare based in Utah, and Group Health Cooperative, based in Seattle.
The consortium is dedicated to developing systems that will allow seamless sharing of health information among provider groups.
The consortium is also committed to working toward a future where timely access to health information improves the quality of care for all patients.
The Partnership for Quality Care is a coalition of not-for-profit health care providers and health care workers dedicated to guaranteed, affordable, high-quality health care for every man, woman, and child in America. The partnership strives to improve patient care as well as prevent and treat chronic conditions by sharing best practices.
Members include Kaiser Permanente, several units of the Service Employees International Union, the Greater New York Hospital Association, Group Health Cooperative and HealthPartners in Minnesota.
In 2008, Kaiser Permanente CEO Halvorson noted: “Leading health care providers have already implemented programs that contain costs, expand access, and most importantly, improve the quality of care for chronic patients. That points the way to nationwide reform.”
Banding together to beat HIV
The HIV Interregional Initiative, a cooperative effort among all Kaiser Permanente regions and Group Health Cooperative, represents the second largest provider of integrated HIV care in the United States; the largest provider is the Veterans Administration.
Sponsors of the initiative are Kaiser Permanente Foundation Health Plan and The Permanente Federation, which represents the national interests of the Permanente Medical Groups.
The Care Management Institute, a partnership between the federation and the health plan, has developed the first clinical guidelines in the United States for HIV/AIDS treatment and the appropriate use of related drugs.
The HIV Interregional Initiative works with Kaiser Permanente’s national pharmacy purchasers to get the best prices for HIV drugs. Research using Kaiser Permanente’s electronic health records has led to exceptional success in treating patients with HIV.
In 2012, Robert Pearl, MD, executive director and CEO of The Permanente Medical Group, noted: “Our success in the treatment of patients with HIV/AIDS results from the excellence of our clinicians, our advanced [information technology] systems, our integrated delivery system and our effective coordination across specialties.”
Kaiser Permanente assists health care providers and community health clinics across the country in improving their HIV patient care by sharing its clinical best practices, provider and patient education materials, training and other expertise.
Genetic research for better chronic care
The Kaiser Permanente Research Program on Genes, Environment, and Health is one of the largest research projects in the United States to examine the genetic and environmental factors that can increase risk for chronic conditions such as heart disease, cancer, diabetes, high blood pressure, Alzheimer’s disease, and asthma.
With DNA collected from 500,000 consenting California health plan members, the project will link comprehensive electronic health records, data on relevant behavioral and environmental factors, as well as genetic information.
Working in collaboration with other scientists across the nation and around the world, researchers hope to translate project findings into improvements in preventive care and treatment.
Henry J. Kaiser started something in 1942 that continues to drive Kaiser Permanente’s quest, 71 years later, to improve health care and access to treatment for all Americans.
, Heritage writer
In a highly technological world, paper medical charts no longer show up in Kaiser Permanente doctors’ hands when they interact with today’s tech-savvy patients. These collections of hand-written notes of our medical complaints, drug prescriptions, lab tests and more, are going the way of fax machines and typewriters.
They’ve been replaced by Kaiser Permanente’s award-winning electronic medical record system, Kaiser Permanente HealthConnect®, which brings patients much closer to their providers.1
But preserved paper patient records going back to World War II will continue to be a valuable asset for research, even as we trade in the old cumbersome model for the new.
Gary Friedman, MD, retired director of the Kaiser Permanente Division of Research in Oakland, Calif., says Kaiser Permanente’s medical records – whether the original hard copies or digital files– are valuable assets to allow groundbreaking research.
In a 1998 article in The Permanente Journal, Friedman wrote: “Our collection of manual charts going back over 50 years is a national treasure and must be preserved despite the storage and retrieval costs entailed.”
In his 2006 oral history, Friedman said the highly touted study on the value of sigmoidoscopy in preventing colon cancer relied on paper records going back to the 1970s.2
He added: “(In) a recent study I did on the early symptoms of ovarian cancer (we found) by going into the charts (paper records) we could get much more of what the physicians recorded in text about the symptoms these women were having . . . Who knows what question might come up in the future (that could be answered) by looking at these charts that go back to the mid-1940s?”
Kaiser Permanente’s early foray into digital world
Kaiser Permanente’s journey into electronic record keeping started around 1960 and took advantage of emerging computer technology. A desire to prevent chronic disease through pre-symptom screening supplied the motivation to automate routine tests and to compile anonymous patient data for population-based research.
Barbara Breen, a medical assistant at Kaiser Permanente Oakland Medical Center in the early 1970s, had her hands on paper charts as well as on the pioneering electronic medical records of the day. She often stood by as lunch-time relief to ensure the computer ran fluidly as it processed punch cards that coded the results of patient visits for Kaiser Permanente’s complete physical (multiphasic) examination.
She was on the cutting edge of computer technology of the time and was in awe. “I got to see all these brand new machines and they assigned me to the spirometer (to test lung capacity),” Breen recalled recently. “The patients filled out a medical questionnaire (health assessment) and had 90 minutes to go around to all the cubicles where they had the tests.”
Data collected by Breen and others in the multiphasic unit were fed into early computers that took up the basement at 3779 Piedmont Ave., just off of MacArthur Boulevard near Kaiser Permanente’s flagship medical center in Oakland, Calif.
Tracking members’ health over decades
Over the years, these records, now considered invaluable and precious, have been the basis for many Kaiser Permanente longitudinal research projects. Collection of detailed patient data from 1964 to 1972 was made possible by the pioneering computer work of Morris Collen, MD, largely funded by the federal government.
Breen, who worked for Kaiser Permanente for 30 years mostly in the northern San Francisco Bay Area, recalls having the duty to retrieve charts for patients scheduled to come into the San Rafael facilities in the 1970s.
“I got a job down on Fourth Street, which was an old motel . . . General Medicine was downstairs and Internal Medicine was upstairs, and the garage next door is where all the charts were. And in those days, we didn’t have (access to) computers yet, so if you needed a chart ASAP you would order it by phone.
“The chart room didn’t always have an extra person to bring the chart over. So the medical assistant or other (staff person) went out, rain or shine, across the parking lot, into the remodeled garage and picked up your chart.”
Today, Kaiser Permanente medical centers are constructed without medical chart rooms, indicating a confidence that the electronic chart is here to stay. With KP HealthConnect® in place, patients get their routine test results much quicker, and they can discuss their care with their physicians via secure email and mobile devices.
For member convenience, patients who travel can have their medical data downloaded on to a memory stick to take wherever they go. For quality of care, physicians have access to patients’ medical information in any of Kaiser Permanente’s facilities nationwide, enabling better care and avoiding duplication of tests.
1 Kaiser Permanente has been awarded Stage 7 honors by the Health Information Management Systems Society Analytics for 36 of its hospitals. Stage 7 is the highest award in the category and recognizes environments in which paper charts are no longer used to deliver patient care. KP was also honored with the HIMSS Davis Award for excellence for 2011. The 2013 annual HIMSS conference is under way in New Orleans through Thursday, March 7.
2 Selby, JV, Friedman, GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. New England Journal of Medicine 1992.
Also see: “Screening for Better Health: Enter the Computer”
, Heritage writer
Kaiser Permanente founding physician Sidney Garfield had good advice for his Northern California colleagues in 1974. He basically told them to stick together. “Keep your arms on each other’s shoulders and keep your eyes on the stars for innovation and change for the future.”
The executive medical directors took that sage advice in 1997 and created The Permanente Federation (the Federation) to serve the collective interests of the physicians to deliver the highest quality medical care through partnership with Kaiser Foundation Health Plan.
This year, the Federation marks the 15-year anniversary of this collaboration, which has contributed to Kaiser Permanente’s high-performing integrated care delivery system, the creation of a cutting-edge national electronic health records system, a formal sharing of best medical practices, and a shared vision for the future of health care.
In his talk to KP physician leaders 38 years ago, Garfield was speaking from the perspective of someone who had locked horns with traditional fee-for-service medicine over prepaid group practice. He understood that in order for physicians to be able to deliver the highest quality care, they need to be well-positioned to advocate for their patients.
Creating a balance
Permanente physicians have rubbed elbows with Washington movers and shakers over the years. Here, Sidney GarfieldThe alignment of KP’s medical groups created an effective model for collaboration with the eight Kaiser Permanente regional Health Plans and Hospitals. Today, this collaboration continues to drive ongoing dialog through the Kaiser Permanente Program Group, the joint strategic leadership body, and is recognized for its balanced leadership and shared commitment to patient-centered care.
In the inaugural issue (summer 1997) of The Permanente Journal, KP’s peer-reviewed medical journal, Oliver Goldsmith, MD, first chairman of the Federation’s Executive Committee, described the need for physician alignment: “We must assure the value (of putting patient interests first) remains central and (we must) prove incorrect the creeping notion that group practice does not offer an appropriate solution to our nation’s health care problems.”
In the June 2002 issue of Managed Care magazine, former KP CEO and President David Lawrence, MD, noted that new opportunities for collaboration through the Federation represented a change necessary to KP’s continued success. “. . . We now can start to take advantage of our intellectual scale, this incredible experience that occurs across all the geographic areas with all the clinicians and all the Health Plan executives,” Lawrence told the magazine.
Federation progresses toward its goals
On the Federation’s 10th anniversary in 2007, Jay Crosson, MD, the first Federation executive director, gave his evaluation of its success: “In the areas of quality and service improvement, IT development, external relations, and other endeavors, the renewed partnership among the Federation, Health Plans, and organized labor (through the Labor Management Partnership) has been a historic contribution to maintaining KP’s reputation for excellence and superior value.”
Today, the Federation represents approximately 17,000 physicians in eight Permanente Medical Groups nationwide, caring for more than 9 million Kaiser Permanente members. Jack Cochran, MD, the current executive director, offers his perspective on the Federation’s first 15 years:
“Over the years, the partnership between the PMGs and the Federation to leverage advanced technology, create innovative ideas, and share best practices has advanced our clinical quality. Ingrained in KP’s physician culture and rooted in Sidney Garfield’s leadership and vision, is our commitment to provide excellent care through evidence-based medicine that puts the patient first, always.”
CMI helps transform care delivery
The Care Management Institute, also established in 1997, partners with the PMGs and the Kaiser Foundation Health Plan to realize Kaiser Permanente’s vision of consistent, high-quality care.
CMI works with physicians and researchers in all eight Kaiser Permanente regions to gather new epidemiological research and outcomes information and to develop evidence-based best practices to share with all KP physicians and other health care professionals.
“CMI was established to optimize care quality, to further KP’s mission in improving the health of its members, and to transform its health care culture,” said CMI’s Executive Director Scott Young, MD. “We spread clinical best practices, develop integrated care delivery models with regional partners, and support the national program by working with physicians, clinical experts and leaders throughout KP.”
In his 1997 Journal article, Dr. Goldsmith summed up the potential of KP’s partnerships: “A truly national Kaiser Permanente, with a growing Kaiser Foundation Health Plan and a growing Permanente medical practice across the United States, can be the most powerful contribution to improving American health care in our organization’s storied history.”
, Heritage writer
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.
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
“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 quality honors:
, Heritage writer
Third in a series
As the 1970s drew to a close, physicians and quality reviewers nationwide were probing and struggling to make a faulty “medical audit” system work to evaluate and improve the health care of millions of Americans, young and old, well and sick, rich and poor.
In three Kaiser Permanente regions, physicians and quality auditors had received federal grants to apply the medical records retrospective review or traditional method endorsed by state medical associations, the Joint Commission for Accreditation of Hospitals (JCAH), and Medicare and Medicaid officials.
Southern California, Hawaii and the Northwest KP regional medical groups obtained three-year grants under the EMCRO (Experimental Medical Review Organizations) project to put the traditional medical audit system into practice and find out how well it worked. It didn’t.
Northern California quality pioneers forge their own model
In Northern California, quality guru Len Rubin, MD, PhD, had taken a different path. “I think they (Northern California) were a bit smarter than us (SCPMG),” admitted Sam Sapin, MD, KP Southern California quality leader in the 1970s and 1980s.
As early as 1973, Rubin was piloting a new quality assessment method in all 13 of the Northern California KP medical centers. Rubin’s system, called Comprehensive Quality Assurance System (CQAS), had reviewers checking medical records of patients who had just been discharged from the hospital. The emphasis was on finding deficiencies in real time and auditing problem cases for questionable practices that may have contributed to bad outcomes.
“He (Rubin) really pioneered the problem-focused approach to quality of care assessment and assurance,” Sapin said. “His motto was and is, “Find out what’s wrong, not what’s right, then fix it.” Rubin published his CQAS protocol in 1975 for the American Group Practice Association.
Best to measure process or outcome?
In developing his model, Rubin was acutely aware of the difficulty of defining the relationship between process – delivery of care and drug administration – and the outcome of those treatments. Rubin argued that there are many “outcomes” in the continuum of care and many factors don’t affect the ultimate outcomes of good health, ability to return to work, or at the other end of the spectrum death or chronic illness or disability.
“As can be seen, there are endpoints here (or outcomes) relating to many departments (laboratory, record room, physician, pharmacy, patients, etc.). Often the outcome of one process is the input for another,” Rubin wrote in his 1975 CQAS publication.
“Further confusion lies in the time-dependence of outcome. The outcome may differ enormously, depending upon whether it is being measured immediately after treatment, several months after treatment, or several decades after treatment,” he continued. “Latent drug effects only now becoming known completely invalidate previous judgments that some outcomes were good in the long term. He concluded: “There is no way to measure ‘ultimate outcome.’ ”
Different schools of thought cloud issue
Sapin reported that at this time debate was raging between the “outcome” and the “process” people. “The process people say outcomes are too difficult to measure and interpret correctly; one should only compare outcomes of cases of comparable severity and one should also take into account all of the intervening variables (e.g. patient compliance, income level, lifestyle) which cannot be controlled by the provider and yet will affect the outcomes.
“On the other hand, the outcome people say don’t bother to assess process because many processes do not correlate well with outcomes and some may even lead to bad outcomes. The safety and efficacy of many of the things we do to and for patients have never been scientifically validated,” Sapin said in his 1983 presentation to the Board of Directors, “Historical Perspectives on Quality of Care.”
In 1973 as Rubin tested and refined his method, Jim Vohs, KP’s CEO, set up the KP board of directors’ Subcommittee on Correlation of Quality of Care and established a new department to focus on quality. Vohs also established the Interregional Quality Assurance Committee (IRQAC), with quality representation from all KP regions.The group came together at least once a year to compare quality notes. Giving program-wide quality a high priority, Vohs accompanied surveyors on all the committee’s facility visits in the regions.
Rubin’s system had an almost twin at the state level
Ironically, in the early 1970s the California Medical Association (CMA) and the California Hospital Association (CHA), responding to the rise of malpractice insurance rates, devised a “problem-focused” or “generic-screening-criteria” method similar to Rubin’s. Even though both agencies required the traditional medical audit for their member organizations, they decided to use a different method to identify outcomes that could become subjects of malpractice lawsuits.
The CMA-CHA method called for the review of medical records upon a patient’s discharge to identify adverse outcomes. In reviewing charts, they measured quality according to 20 standards to find problems. Examples of the screening criteria were unplanned removal of an organ, repeat of an operation during the same hospital stay and development of a heart attack after admission. CMA-CHA’s “Medical Insurance Feasibility Study” was published in 1978.
By 1980 the traditional medical audit had become a dinosaur in the world of quality assessment and assurance in favor of a problem-focused method.Review organizations move away from medical audits
In 1980 JCAH quietly abandoned the traditional medical records audit. JCAH’s new published standards required hospitals to have a documented quality assurance program but no specific audit program was mandated. Members of the federal Professional Services Review Organizations (PSROs), local agencies designated by Medicare and Medicaid to study quality of care, were also disappointed by the medical audit results and phased out the method.
In its 10th anniversary issue in 1984, the JCAH journal re-published Sapin’s 1980 groundbreaking article, “A Region-wide Quality of Care Monitoring and Problem Delineation Plan.” The article authored by Sapin, Gerald Borok, MPH, and Cheryl Tabatabal, rejected the traditional medical audit and described the problem-focused review scheme he and Rubin had developed and piloted.
In a 10-year anniversary reflective commentary, William C. Felch, MD, Quality Review Bulletin Editor and New York internist, recognized the new KP-generated system and touted the plan as “ambitious, carefully thought out and planned.” He added: “The question five years later is how did it all work out?”
Next time: Birth of the National Committee for Quality Assurance
, Heritage writer
First in a series
In the beginning of the modern era of medicine there were doctors and patients. To judge the quality of care was to ask: Did the patient live? Is the patient thriving? Doctors had little science to back up their methods. They followed conventions and did what they thought was best for the patient. If a doctor went wrong, no formal mechanism existed to correct his (or her) ways.
Hard to imagine how we got from such early simplicity to today’s complicated state of quality affairs. Our 2012 definition of quality encompasses a myriad of considerations: timely access to care, science-based treatment, adherence to well-defined practice protocols, and appropriate use of technology. Preventive care screenings, such as mammograms and colon studies to catch cancer early, and access to health education so patients can learn to avoid disease are key factors in assessing the quality of care of a provider organization.
Figuring out the best way to judge quality of care has been a monumental quest pursued by health care providers and consumers alike since the early 1950s. This pursuit has been embraced by numerous medical, government and consumer agencies in the past 50-plus years, creating a veritable alphabet soup of regulatory and review/rating organizations with varying degrees of effectiveness and longevity.
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.
, Heritage writer
When we talk about quality of care today, the name “Jim Vohs” inevitably comes up. That’s because many Kaiser Permanente (KP) people have heard of the annual James A.Vohs Award for Quality. It’s a great honor to receive the Vohs award, and every year since 1997 people across the program have pulled out all stops to garner the coveted distinction for quality improvement projects. But fewer people know the story of James A. Vohs, the man behind the name, and why he is associated with quality assurance.
Jim Vohs was an early health plan leader, a champion of prepaid, group medical practice, a believer in strong partnerships between health plans and the medical groups, and an adamant advocate for Kaiser Foundation Health Plan and Hospitals as nonprofit institutions that provide quality, affordable health care.
Right out of Berkeley High School in 1946, Vohs first worked as a “mail boy” for a Kaiser Industries unit called Kaiser Services, where his mother worked as a bookkeeper. After his graduation from UC Berkeley in 1952, he rejoined Kaiser Services, which provided administrative support for the various Kaiser industrial companies, like Kaiser Steel, Kaiser Aluminum and Kaiser Engineers.
With his career blossoming, he shocked his Kaiser Services colleagues by choosing to switch to the nonprofit Kaiser Foundation Health Plan and Hospitals in 1957 because he believed in its principles. It was a good choice. During a 50-plus year career, he rose to become President and CEO as well as the first chairman of Foundation Health Plans and Hospitals boards of directors who was not a Kaiser family member, succeeding Edgar F. Kaiser, Henry J. Kaiser’s son.
Quality a big priority
Quality of care was an issue early on in the life of the Kaiser Permanente Medical Care Program. Detractors of prepaid, group practice were quite happy to spread rumors about how Kaiser Permanente doctors were not qualified or competent and that their patients were “captives” of no choice.
Vohs was very much aware that these attacks contributed to a “poor reputation,” however wrong, in KP’s early days. Even the prevailing attitude at Kaiser Services was that the medical care program was an “embarrassment.”
Meanwhile, Kaiser Permanente was early and quick in its efforts to show the skeptical world evidence of its excellent care. Early physicians published research that showcased their innovative treatment, sponsored medical symposiums, aligned themselves with academic medicine, and kept their heads down when the insults were hurled.
Reputation aside, Jim Vohs had faith in the high caliber of Permanente physicians, and he bravely faced critics who implied Permanente cut corners in medical treatment. “It is quite clear to me that the economic incentive . . . for the program and the participating physicians —who by and large spend their careers (with Permanente) — is to resolve medical problems as promptly and completely as possible,” Vohs told an interviewer in 1983.
Documenting quality of care
Today’s medical quality movement got its start with the creation of the Joint Commission on the Accreditation of Hospitals in 1952. The federal government started requiring quality data following the adoption of Medicare for the retired and Medicaid for the poor in 1965. The American Hospital Association published its Quality Assurance for Medical Care in the Hospital in 1972. The HMO (Health Maintenance Organization) act of 1973 required each federally qualified HMO to have an internal quality assurance program.
In 1974, Kaiser Permanente physicians from all regions started meeting regularly to discuss quality related issues, and Vohs established a department of quality and a board of directors committee on quality assurance. The committee, including Vohs, made site visits to each of the regions several times a year.
In 1979, Drs. Leonard Rubin and Sam Sapin served on an advisory committee that set up the National Committee for Quality Assurance (NCQA), which sets standards for HMOs. The Permanente physicians were successful in getting the committee to adopt a problem-focused approach to quality assessment, which Rubin had developed and tested starting in 1967.
By 1983, Kaiser Permanente was getting good reviews. Dr. Sapin reports: “Almost without exception, published reports comparing health care delivery by Kaiser Permanente physicians to others have shown us to be better than or at least equal to others.”
Vohs is proud of having the quality award as part of his legacy: “It’s so important for Kaiser Permanente. The regions are competing for the award; they are supporting programs in quality because they want to win that award.”
Vohs a key player in KP milestones
Throughout the years, Vohs played a key role in many of the milestones of Kaiser Permanente’s history. Each chapter helped to make Kaiser Permanente stronger and more capable of providing high quality care.
• Passing of the Federal Employees Benefits Act in 1959. This legislation was heavily influenced by Kaiser Permanente leaders who urged Congress to include a choice of fee-for-service and prepaid medical plans. Kaiser Permanente gained many members as a result.
• Passing of the HMO Act of 1973. Kaiser Permanente leaders also heavily influenced this legislation. They worked with Health, Education and Welfare Agency officials to develop a proposal for a per-person or capitation method of Medicare reimbursement for health maintenance organizations (HMOs), which became part of the act.
• Formalizing Equal Employment Opportunities (EEO) and Affirmative Action practices in the 1960s and 1970s. Opening a Kaiser Permanente EEO conference in 1976, Vohs reaffirmed Kaiser Permanente’s commitment to the employment of minorities and women. He reported an increase of minority and women employees from 4,600 in March 1974 to 5,084 a year later, almost one third of the total work force at the time. Women held 56 percent of the management or supervisory positions in 1975, up 2 percent from 1975; minorities held 14 percent of the top jobs in 1975, compared to 13 percent a year earlier.
Vohs affirmed KP’s historical “one-door, one-class” system of health care dating back to 1945. “Each member is entitled to necessary medical care of the same quality, in the same place, irrespective of income, race, religion or age. Given this policy, it would make little sense if we were to discriminate in our employment practices.”
• Partnership and eventual takeover of the Georgetown Health Plan strategically located in Washington, D.C. This medical care program provided the springboard for the creation of our Mid-Atlantic States region.
• Convening a meeting among health plan and medical group leaders in 1996 to re-confirm the principles of the historic 1955 Tahoe Agreement. The earlier agreement set up the business relationship and clear authorities for the Kaiser Permanente Health Plan and Hospitals leadership and the Southern and Northern California medical groups. Forty years later, the outcomes of “Tahoe II” were the National Partnership Agreement and the creation of the physicians’ Permanente Federation, which represents all regional medical groups in dealings with the health plan leadership.
Kaiser Permanente on a mission
An able administrator, Vohs believed in the health plan: “There was a sense of commitment to a program that was performing social good and demonstrating a way of providing care and financing that was important to the country.”
Vohs firmly dispatched any insinuation that Kaiser Permanente was like for-profit health plans: “Over the years, Kaiser Permanente has been driven by particular values that essentially relate to providing quality medical care to enrolled members for a fixed monthly premium. We don’t conceive of ourselves as a commercial enterprise,” Vohs told John K. Iglehart of Health Affairs in 1983. Quoted in a New York Times article “King of the HMO Mountain” the same year, Vohs added: “There’s a certain missionary zeal in what we’re doing. We think this is a good model for the way in which medical care ought to be organized – so we want to see it spread.”
The Southern California Region’s Proactive Office Encounter (POE), which promotes preventive care, and the California regions’ programs to prevent heart attacks and strokes, were awarded the 2009 Vohs Awards earlier this year. The Fall 2010 issue of the Permanente Journal carries an article about the POE.