Case Study Organized Health Care Delivery System • June 2009 Kaiser Permanente: Bridging the Quality Divide with Integrated Practice, Group Accountability, and Health Information Technology D ouglas M c C arthy, K imberly M ueller, and J ennifer Wrenn I ssues R esearch , I nc . The mission of The Commonwealth ABSTRACT: Kaiser Permanente—comprising the Kaiser Foundation Health Plan, Kaiser Fund is to promote a high performance Foundation Hospitals, and Permanente Medical Groups in eight regions—is the largest health care system. The Fund carries nonprofit integrated health care delivery system in the United States. The successful evo- out this mandate by supporting lution of this organizational structure in a competitive marketplace has required a close independent research on health care issues and making grants to improve partnership between managers and physicians supported by a culture of physician group health care practice and policy. Support accountability for quality and efficiency. An overarching agenda for achieving excellence for this research was provided by focuses on high-impact health conditions, provides goal-oriented tools to analyze popu- The Commonwealth Fund. The views lation data, proactively identifies patients in need of intervention, supports systematic presented here are those of the authors process improvements, and promotes collaboration between patients and professionals to and not necessarily those of The improve health. Central to this effort is KP HealthConnect, a comprehensive health infor- Commonwealth Fund or its directors, officers, or staff. mation system that integrates an electronic health record with the tools to support physi- cians in delivering evidence-based medicine, coupled with a robust online patient portal that enhances members’ access to and involvement in their care. For more information about this study,      please contact: Douglas McCarthy, M.B.A. OVERVIEW Issues Research, Inc. dmccarthy@issuesresearch.com In August 2008, the Commonwealth Fund Commission on a High Performance Health System released a report, Organizing the U.S. Health Care Delivery System for High Performance, that examined problems engendered by fragmenta- tion in the health care system and offered policy recommendations to stimulate greater organization for high performance.1 In formulating its recommendations, the Commission identified six attributes of an ideal health care delivery system To download this publication and learn about others as they become (Exhibit 1). available, visit us online at Kaiser Permanente is one of 15 case study sites that the Commission www.commonwealthfund.org and examined to illustrate these six attributes in diverse organizational settings. register to receive Fund e-Alerts. Exhibit 2 summarizes findings for Kaiser Permanente, focusing on the Northern Commonwealth Fund pub. 1278 Vol. 17 California and Colorado regions as two examples of the organization’s model. 2T he  C ommonwealth F und Exhibit 1. Six Attributes of an Ideal Health Care Delivery System • Information Continuity Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems. • Care Coordination and Transitions Patient care is coordinated among multiple providers, and transitions across care settings are actively managed. • System Accountability There is clear accountability for the total care of patients. (We have grouped this attribute with care coordination, since one supports the other.) • Peer Review and Teamwork for High-Value Care Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care. • Continuous Innovation The system is continuously innovating and learning in order to improve the quality, value, and patient experiences of health care delivery. • Easy Access to Appropriate Care Patients have easy access to appropriate care and information at all hours, there are multiple points of entry to the system, and providers are culturally competent and responsive to patients’ needs. Information was gathered from Kaiser Permanente’s mutually exclusive contracts built on common vision, leaders, a site visit, and a review of supporting docu- joint decision-making, and aligned incentives. Kaiser ments.2 The case study sites exhibited the six attributes Permanente is considered a “closed” group-model care in different ways and to varying degrees. All offered system, since health plan members generally obtain ideas and lessons that may be helpful to other organiza- care from Permanente physicians—with exceptions, tions seeking to improve their capabilities for achiev- such as when using point-of-service plans or when ing higher levels of performance.3 referred for care outside the system. KFHP and KFH are not-for-profit corpora- ORGANIZATIONAL BACKGROUND tions headquartered in Oakland, California, that share Since its inception in 1945, Kaiser Permanente has a common board of directors. KFHP and its regional become the largest not-for-profit, integrated health care subsidiaries contract with individual, group, and pub- delivery system in the United States, serving 8.6 mil- lic purchasers of coverage to finance a full range of lion members in eight regions: Northern and Southern health care services for members. KFH arranges for California, Colorado, Georgia, Hawaii, the Mid-Atlantic inpatient care, extended care, and home health care for States, Ohio, and the Northwest (Exhibit 3). About three- health plan members in owned or contracted facilities. quarters of the members are in California, the organiza- It owns and operates 35 medical centers—hospitals tion’s birthplace. Its mission is to “provide affordable, with multispecialty outpatient and ancillary services— high-quality health care services to improve the health in California, Oregon, and Hawaii. Outpatient medi- of our members and the communities we serve.” cal office buildings, of which there are 431 across all The Kaiser Permanente Medical Care Program regions, typically offer primary care, laboratory, radiol- comprises three separate yet interdependent enti- ogy, and pharmacy services; some also offer behavioral ties: Kaiser Foundation Health Plan (KFHP), Kaiser health and other specialty care. Foundation Hospitals (KFH), and Permanente Medical The Permanente Medical Groups are multispe- Groups in each region. These entities cooperate to cialty groups of physicians who accept a fixed payment organize, finance, and deliver medical care under (capitation) to provide medical care exclusively for K aiser P ermanente : B ridging the Q uality D ivide 3 Kaiser health plan members in Kaiser facilities. They resource management, and the design and operation of are organized as locally governed professional corpora- the care delivery system in each region. tions or partnerships in each of the eight regions served Kaiser Permanente’s workforce encompasses and are represented nationally by The Permanente almost 167,000 employees of KFHP and KFH and Federation. Working in cooperation with health plan 14,600 physicians in the Permanente Medical Groups. and facility managers, Permanente physicians take In 2008, Kaiser Foundation Health Plan and Hospitals responsibility for clinical care, quality improvement, reported combined revenue of $40.3 billion and capital Exhibit 2. Case Study Highlights Overview: Kaiser Permanente is the largest not-for-profit integrated delivery system in the U.S., serving 8.6 million health plan members through exclusive contracts with physician-governed Permanente Medical Groups in eight regions (14,600 physicians nationwide). Facilities include 35 inpatient medical centers in three states and 431 outpatient medical office buildings located across all regions. Eight affiliated research centers constitute one of the largest nonacademic research programs in the country. Attribute Examples from Kaiser Permanente Northern California and Colorado regions Information Comprehensive health information management system integrating electronic health records with physician order Continuity entry, decision support, population and patient-panel management tools, appointments, registration, and billing systems. Member Web portal for online access to health information and educational resources, shared medical record, visit history, appointment scheduling, prescription refills, lab test results, and secure mes­ aging with the care team. s Care Regional health plans are evaluated on how well they manage patients across the lifetime continuum of care (not Coordination just a care episode), including ongoing linkage with an accountable primary care physi­ ian and team. There is “in- c and Transitions; reach” at every patient contact to check on and address outstanding preventive care needs. System Stratified population and patient-panel manage­ ent: proactive primary care teams leverage ancillary staff and m Accountability* information systems to deliver proven preventive therapies and support patient self-care and lifestyle change. Care and case management and transitional care is provided for patients with uncontrolled disease or complex comor- bidities. Primary care teams in Northern California include a behavioral medicine specialist (licensed clinical psychologist or clinical social worker) who co-manages patients with mental health conditions to support improved outcomes. Peer Review and Integrated prepaid group-practice model inculcates a culture of group accountability for quality and efficiency sup- Teamwork for ported by peer feedback and sharing of unblinded performance data within the group. Medical groups identify and High-Value Care develop internal clinical leaders. Labor–management partnership defines common vision and commitment to shared decision-making involving managers, physicians, and employees. Continuous Promotes organizational learning through in-house journal, annual innova­ion awards, workshops, site visits, and t Innovation local clinical champions. Care Management Institute convenes interregional expert teams to develop evidence- based guidelines, programs, and tools; identifies causes of variation and best practices for local adoption. 21st Century Care Innovation Collaborative tests and spreads in­ ovations to transform primary care using informa- n tion technology. Kaiser hospitals are engaged in collaborative learning to attain the status of World Class Hospitals using rapid-change interventions. Garfield Innovation Center serves as a learning laboratory to support simulation, prototyping, and evaluation of innovations to improve health care delivery. Easy Access to Multiple entry options include call centers for primary care appointments and 24-hour nurse advice, after-hours Appropriate Care urgent care, scheduled telephone visits, and electronic messaging with the care team. Group visits offer regular contact with a multidisciplinary care team and peer support for patients with chronic illness. Culture-specific patient-care modules allow patients to communicate in native language with bilingual staff oriented to cultural norms. Institute for Culturally Competent Care designs programs and tools and guides Centers of Excellence. Training programs develop bilingual staff and certify health care interpreters. *System accountability is grouped with care coordination and transitions since these attributes are closely related. 4T he  C ommonwealth F und spending of $2.9 billion. Spending on community INFORMATION CONTINUITY benefit programs amounted to $1.2 billion for com- Kaiser Permanente has been using information tech- munity health promotion, charity care and safety-net nology for more than 40 years to improve clinical and institutions, professional education, and research. Eight administrative functions.4 Its use of electronic health affiliated research centers constitute one of the largest records (EHRs) dates from the 1990s in some regions.5 nonacademic research programs in the country. Building on this experience, and with the active par- This case study draws primarily from the experi- ticipation of its physicians, Kaiser Permanente in 2003 ence of the Northern California region, with supporting launched a $4 billion health information system called examples from Colorado and other regions (Exhibit 4). KP HealthConnect that links its facilities nationwide Because the organization operates in a decentralized and represents the largest civilian installation of EHRs fashion with regional autonomy to meet local needs, in the United States. As of April 2008, the system was these examples may or may not be typical of the pro- successfully implemented in outpatient clinics in all gram as a whole. eight Kaiser regions. Every Kaiser hospital has the In the Northern California region, about 7,000 essential components of the system and 25 had imple- Permanente physicians serve 3.2 million members mented all modules as of December 2008.6 from the San Francisco Bay area east to Sacramento The EHR at the heart of KP HealthConnect and the Central Valley. In the Colorado region, estab- (purchased from vendor Epic Systems Corp.) provides lished in 1969, about 480,000 members receive care a longitudinal record of member encounters across from 800 Permanente physicians in the Denver- clinical settings and includes laboratory, medication, Boulder area and from affiliated community physicians and imaging data. HP HealthConnect also incorporates: in the Colorado Springs area. Market share for the two regions is about 44 percent and 16 percent in their • electronic prescribing and test ordering (com- respective market areas, composed predominantly of puterized physician-order entry) with standard commercial coverage (87% and 85% respectively) and order sets to promote evidence-based care Medicare (11% and 13%). • population and patient-panel management tools such as disease registries to track patients with chronic conditions Exhibit 3. Kaiser Permanente Regions Note: Circles represent approximate geographic service areas. Source: Adapted from information on the Kaiser Permanente Web site. K aiser P ermanente : B ridging the Q uality D ivide 5 Exhibit 4. Kaiser Permanente Service Areas: Northern California and Colorado Regions Source: Kaiser Permanente. • decision support tools such as medication-safety prescriptions, and send secure electronic messages to alerts, preventive-care reminders, and online their care team or pharmacist.7 Online laboratory test clinical guidelines results—the most popular online function—include links to a knowledge base of information on test results • electronic referrals that directly schedule patient and related self-care strategies. A pilot project is testing appointments with specialty care physicians the capability for members (initially Kaiser employ- • performance monitoring and reporting capabilities ees) to transfer information securely from My Health • patient registration and billing functions Manager to Microsoft Corporation’s HealthVault per- sonal health record application.8 KP HealthConnect is designed to electronically Physician leaders report that access to the EHR connect members to their health care team, to their in the exam room is helping to promote compliance personal health information, and to relevant medi- with evidence-based guidelines and treatment proto- cal knowledge to promote integrated health care. For cols, eliminate duplicate tests, and enable physicians example, members can complete an online health to handle multiple complaints more efficiently within risk assessment, receive customized feedback on one visit.9 A study in the Northwest region found that behavioral interventions, participate in health behavior patient satisfaction with physician encounters increased change programs, and choose whether to send results after the introduction of the EHR in exam rooms to KP HealthConnect to facilitate communication with there.10 Early findings from ongoing hospital imple- their physician. mentations suggest that the combination of computer- To more fully engage patients in their care, ized physician-order entry, medication bar-coding, and physicians and staff encourage them to sign-up for electronic documentation tools is helping to reduce enhanced online services. As a result, more than medication administration errors. one-third of health plan members nationwide (and Use of the EHR and online portal to support nearly one-half of members in Northern California) care management and new modes of patient encounters are using a Web portal called My Health Manager to appears to be having positive effects on utilization of track selected medical information from the EHR, services and patient engagement. For example, three- view a history of physician visits and preventive care quarters or more of online users surveyed agreed that reminders, schedule and cancel appointments, refill the portal enables them to manage their health care 6T he  C ommonwealth F und Exhibit 5. Kaiser Permanente Hawaii: Distribution of Patient Contacts, 1999–2007 Contacts per member Secure messaging* Scheduled telephone visits 7 Office visits 6 0.02 0.03 0.11 0.23 0.02 0.03 0.04 0.09 0.17 5 0.63 1.13 1.68 4 5.34 5.19 3 5.27 5.15 5.12 5.01 4.77 4.13 3.70 2 1 0 1999 2002 2001 2002 2003 2004 2005 2006 2007 *Measurement for secure messaging began in 2005. Source: Kaiser Permanente. effectively and that it makes interacting with the health with the organization across time and the continuum of care team more convenient.11 Patients in the Northwest care—clinic, hospital, home, hospice, or extended care. region who used online services made 10 percent fewer The Northern California region, for example, primary or urgent care visits than before they had stresses “in-reach” to patients at every contact (not just online access (7 percent fewer visits compared with a during primary care visits) to check on outstanding control group of patients).12 preventive care needs and to schedule services such The Hawaii region experienced a 26 percent as mammograms. Medical assistants receive feedback decrease in the rate of physician visits following reports that prompt them to follow-up with patients implementation of KP HealthConnect (Exhibit 5). whose preventive care needs were not addressed dur- Overall patient contacts increased by 8 percent due ing a recent clinic visit. As a result of such in-reach and primarily to a large increase in scheduled telephone outreach efforts, the plan’s breast cancer screening rate visits. Urgent care and emergency department visits in 2007 was 79 percent among women (ages 40 to 69) increased, although the increase accounted for only with private coverage and 86 percent among Medicare about 5 percent of the decrease in office visits. The members, as compared with national rates of 69 per- authors speculated that the EHR facilitated more- cent and 67 percent, respectively. efficient care delivery and helped doctors resolve Regions are evaluated on how well members are problems over the telephone.13 linked or “bonded” to a primary care physician and an “accountable unit” (module or team of providers) that CARE COORDINATION AND TRANSITIONS: is responsible for coordinating and ensuring continuity TOWARD GREATER ACCOUNTABILITY FOR of care. This whole-person perspective may contribute TOTAL CARE OF THE PATIENT to member loyalty: California members stay enrolled Having a broad spectrum of services available within for 14 years on average, compared with four years for one organization and, in many cases, in one location, competitors. makes it easier to coordinate care for patients. Kaiser Permanente’s integrated model of care focuses not only Improving Population Health. The Northern on the spectrum of medical care that a patient may California region uses a population and patient-panel need at any one time, but also on members’ interactions management strategy to improve care and outcomes K aiser P ermanente : B ridging the Q uality D ivide 7 for patients who have—or who are at risk for devel- patient, such as increasing medication dosage or order- oping—chronic diseases. This approach is built on the ing a test. The medical assistant or nurse then contacts philosophy that a strong primary care system offers the the patient to relay the physician’s instructions, using most efficient way to interact with most patients most prepared scripts to ensure consistent communication. of the time, while recognizing that some patients need Contact is typically made by telephone but may occur additional support and specialty care to achieve the by letter in some cases. best possible outcomes. Patients are stratified into three At level two, care managers (specially trained levels of care: nurses, clinical social workers, or pharmacists) support the primary care team to help patients gain control of a 1. Primary care with self-care support for the chronic condition. Interventions may include providing 65 percent to 80 percent of patients whose self-care education, titrating medications according to conditions are generally responsive to lifestyle protocol, and making referrals to educational classes changes and medications. (e.g., for smoking cessation). The goal is to move patients back to level one after an intervention period 2. Assistive care management to address adher- of several months to a year. Successful transitions ence problems, complex medication regimens, require that primary care teams be prepared to follow and comorbidities for the 20 percent to 30 per- up with patients and prevent them from relapsing. Care cent of patients whose diseases are not under managers may be part of the local primary care team or control through care at level one. may be centrally located at a medical center, depending on local resources. 3. Intensive case management and specialty An example of intensive case management care for the 1 percent to 5 percent of patients (level three) is a cardiac rehabilitation program called with advanced disease and complex comor- Multifit for patients with advanced heart disease, such bidities or frailty. as those recovering from a heart attack or heart surgery. Nurse case managers provide telephonic education Level one emphasizes a proactive team and support for up to six months to help patients make approach that conserves physician time for face-to- lifestyle changes and reduce their risk of future cardiac face encounters by enhancing the contributions of events. Aided by the EHR and a patient registry, the ancillary staff (medical assistants and also nurses and Colorado region enhanced the program by adding a tel- pharmacists in some locations) to conducting outreach ephonic cardiac medication management service pro- to patients between visits. The team uses a population vided by clinical pharmacy specialists, with ongoing database and decision support tools built into the EHR follow-up until patients achieve treatment goals and to track patients with chronic conditions such as dia- can be transferred to primary care for maintenance.14 betes or heart disease, develop action plans to engage Results for patients participating in the Colorado pro- them in self-care, ensure that they are taking appropri- gram included the following: ate medications, and remind them to get preventive care and other tests when needed. • Cholesterol screening increased from 55 per- Outreach to patients with chronic conditions cent to 97 percent of patients, while cholesterol typically occurs as follows: The physician reserves control has almost tripled from 26 percent to 73 a weekly appointment slot to meet with his or her percent of patients.15 The Colorado plan ranked staff and review a computer-generated list of 10 to 20 first among health plans nationally in 2007 on patients who are not achieving treatment goals. The a measure of cholesterol screening for patients physician indicates follow-up instructions for each with cardiovascular conditions.16 8T he  C ommonwealth F und • Relative risk of death declined by 89 percent • The prevalence of adult smoking declined among those enrolled in the program within 90 from 12.2 percent to 9.2 percent of members days of a cardiac event, and by 76 percent for from 2002 to 2005, more than twice the rate of those with any contact with the program.17 An improvement in the California population as a estimated 260 major cardiac events and 135 whole (Exhibit 6). deaths have been avoided per year because of • Blood pressure control more than doubled, from these improvements.18 36 percent of patients with hypertension in 2001 The Northern California region in 2004 initi- to 77 percent of 313,000 patients with the con- ated a program called PHASE—Prevent Heart Attacks dition by the third quarter of 2008 (Exhibit 7). and Strokes Everyday—to consistently deliver proven The plan ranked third-highest in the nation on prevention therapies for controlling blood pressure, this measure in 2007, according to the National blood lipids, and blood glucose among a broadly Committee for Quality Assurance (NCQA). defined population of patients at risk for cardiovascu- • Appropriate receipt of target prescription medi- lar disease. Diabetics make up two-thirds of the target cations increased from 41 percent to 53 per- population, which also includes patients with coronary cent of PHASE patients from 2004 to 2008.19 artery disease, stroke, chronic kidney disease, periph- Blood glucose control (hemoglobin A1c <9%) eral arterial disease, and abdominal aortic aneurysm. improved from 66 percent to 73 percent of dia- Interventions include prescribing four drugs whenever betic patients, while cholesterol control (LDL-C appropriate—aspirin, lipid-lowering medications, ACE <100) improved from 50 percent to 63 percent inhibitors, and beta-blockers—and promoting four of all PHASE patients from 2005 to 2008. lifestyle changes: tobacco cessation, physical activity, • Hospitalization rates (age/sex adjusted) declined healthy eating, and weight management. by 30 percent for coronary heart disease, by 56 Focusing on the entire spectrum of primary, sec- percent for ST-elevated myocardial infarction ondary, and tertiary prevention for cardiac care man- (heart attack), and by 20 percent for strokes agement has resulted in the following improvements in from 1998 to 2007. care and outcomes in the Northern California region: Exhibit 6. Kaiser Permanente Northern California: Adult Smoking Prevalence in 2002 and 2005 Percent of adult population who currently smoke 25 23.0 2002 2005 20.9 20 Healthy People 2010 16.4 Goal 12% 15.2 15 12.2 10 9.2 5 0 United States California Kaiser Permanente Northern California Source: Kaiser Permanente. K aiser P ermanente : B ridging the Q uality D ivide 9 Exhibit 7. Kaiser Permanente Northern California: Trend in Blood Pressure Control Rate: 2001–2008 Percent of hypertensive patients with blood pressure under control (<140/80) 100 80 75 75 77 75 77 71 72* 60 61 64 60 56 53 40 48 43 5.01 4.77 36 4.13 3.70 20 0 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2001 2002 2003 2004 2005 2006 2007 2008 *Measure definition changed in 2006 from population ages 46–85 to ages 18–85. Source: Kaiser Permanente. • The heart disease mortality rate decreased by medicine specialist co-manages patients with identified 26 percent from 1995 to 2004. As of 2004, mental health conditions such as depression or anxiety Northern California Kaiser Permanente mem- disorders, providing counseling (using proven modali- bers had a 30 percent lower chance of dying ties such as cognitive behavioral therapy or behavioral from heart disease than other Californians activation) and problem-solving support individually or (Exhibit 8). in group sessions. The patient’s primary care physician is responsible for medication management. Patients Integrating Behavioral Health and Primary Care. with severe mental health conditions or substance use Each primary care team in Northern California disorders are referred to psychiatric specialty care or includes a behavioral medicine specialist, who is a chemical dependency treatment. licensed clinical psychologist or clinical social worker trained to work in primary care. The behavioral Exhibit 8. Kaiser Permanente Northern California: Heart Disease Mortality 1995–2004 Deaths due to heart disease per 100,000 population* 300 274 269 265 263 252 250 230 220 208 202 188 200 183 182 183 183 150 173 171 172 167 156 136 100 Rest of California 50 Kaiser Permanente Northern California region 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 *Age- and sex-adjusted to the 2004 Kaiser Permanente standard population. Source: Kaiser Permanente Northern California Division of Research. 10T he  C ommonwealth F und Since many patients have co-occurring mental Improving Medication Safety. The Colorado region and physical conditions, colocation of behavioral medi- developed a computerized pharmacy alert system that cine specialists in primary care allows a broad perspec- reduced the relative risk of dispensing potentially tive that is superior to disease-specific approaches. inappropriate medication by 16 percent among elderly It also improves access to mental health care, since patients. When an elderly patient is prescribed a poten- many patients prefer to receive such services from their tially inappropriate medication, the system notifies a primary care team and may not visit mental health spe- pharmacist, who contacts the physician by phone or cialists even when referred. e-mail to review the order using a standard question- Through its participation in a study of a collab- naire and to recommend changes when warranted.22 orative care model called IMPACT, the organization For patients taking anticoagulation medication, a tel- learned that outcomes could be enhanced by adopting ephonic, clinical pharmacist–managed anticoagulation a more systematic approach to caring for patients with service reduced the risk of therapy-related complica- depression. As a result, the region recently began using tions by 39 percent compared with usual care.23 a population database and a patient-completed ques- tionnaire called the PHQ-9 to track patients’ progress Measuring Financial Outcomes. Assessing the eco- and provide feedback so that the physician and behav- nomic benefits of disease management can prove ioral medicine specialist can tailor treatment to achieve difficult. A 2004 study of outcomes in Northern symptom-improvement goals.20 The region ranks California reported mixed results: Costs increased at second among health plans nationally on a measure of a lower rate in disease-managed groups of patients antidepressant medication management–acute phase with a particular chronic condition than in a compari- treatment, according to the NCQA. son group of patients without the condition. However, total costs did not decrease in absolute terms. Quality Improving Transitional Care. The Colorado region of care improved, but “there was no tendency for offers a telephonic care coordination program to costs to increase less at medical centers where quality improve follow-up care for patients discharged from improved more.” 24 Permanente physician leaders com- a hospital or skilled nursing facility. The program mented that the region had already achieved substantial also services patients who frequently visit the emer- benefits from disease management programs by the gency department (ED) or are at risk of hospitalization time of the study, helping to keep premiums below the because of multiple chronic conditions. national average.25 Such programs provide better value Care coordinators (specially trained nurses or for patients and purchasers through improved health social workers) contact discharged patients within 24 outcomes and workplace productivity, said Warren hours to assess needs and stratify them to receive short- Taylor, M.D., medical director for chronic condition or longer-term services that may include verifying management in the Northern California region. medications, developing self-care skills, coordinating services, and making referrals to community resources. PEER REVIEW AND TEAMWORK FOR Information on each patient contact is documented in HIGH-VALUE CARE the EHR for communication to the care team. A multispecialty group practice creates organic connec- The plan credited the program with annual cost tions among physicians, but also requires intentional savings of $4 million from decreased readmissions management effort to achieve its potential. Sharon (2.4% of intervention patients vs. 14% of usual-care Levine, M.D., associate executive director of The patients at 12 months) and ED visits (7% vs. 16%, Permanente Medical Group of Northern California, respectively). Satisfaction with the program exceeds 90 described the culture as one of group accountability: percent of physicians and 95 percent of patients.21 focused on education and information in lieu of regula- tion, and motivated by a sense of commitment rather K aiser P ermanente : B ridging the Q uality D ivide 11 than compliance. Internal transparency—a willingness engenders trust and commitment while recognizing to share peer feedback (aided by a common medical and rewarding performance. Permanente physicians are record) and unblinded performance data within the paid market-competitive salaries (based on specialty), medical group—has become the most powerful driver so there is no financial incentive for either under- or of performance improvement during the past 10 years, overtreatment. From its capitation payment, the medi- she said. This principle of group responsibility defines cal group funds an incentive pool with rewards based the core of “Permanente Medicine” and promotes clini- on meeting quality and service goals at each organi- cal collaboration and coordination across specialties. zational level: group, medical center, department, and Under prepaid care, Permanente physicians take individual physician. Physicians are eligible to earn responsibility for both quality and cost of care. They an annual performance incentive payment of up to 5 are stewards of both member resources and member percent of salary (on average) based on measures of health: accountable to their patients, to the membership quality, service and patient satisfaction, workload, and as a whole, to their peers, and to the health plan. There group contribution. is a shared sense that wasted resources represent a lost Another characteristic of the Kaiser Permanente investment in member health. Given this dual account- partnership ethic is the organization’s relationship to ability, physician leaders maintain trust by being clear its labor unions. Organized labor has been a key source about the motivation for making changes: An initiative of support for the Kaiser Permanente model since its intended primarily to improve efficiency is never pre- inception. As collective bargaining became strained sented as one intended to improve quality, Levine said. in the 1990s because of pressure to cut costs, Kaiser Physicians exercise this accountability through Permanente and a coalition of its labor unions estab- medical group self-management and self-governance, lished the Labor Management Partnership in 1997 to as full and equal partners with the health plan. This foster a more positive relationship. Described by aca- partnership is formally defined through annual agree- demic experts as historic in its scope and accomplish- ments at both the national and regional levels and ments, the Partnership has defined a jointly agreed- is given practical expression through joint decision- upon vision and commitment to a shared decision- making bodies and day-to-day collaboration between making process involving managers, physicians, and physician leaders and health plan and facility managers employees.27 at all levels. About one in seven physicians is involved The integration of labor into organizational in some kind of leadership role in Northern California. decision-making is credited with facilitating opera- Physician leaders emerge from the ranks and are given tional and financial improvements and with improving management and leadership development training as employee morale.28 Although the organization’s decen- needed to be successful in their roles.26 tralized structure has sometimes created challenges in While emphasizing partnership and integration, disseminating the partnership at every level, a reaf- “Permanente physicians pride themselves on their clin- firmation of partnership principles emphasized their ical autonomy,” Levine said. For example, physicians consistent application through teamwork. do not need approval to deviate from the drug formu- lary if warranted for a particular patient. This practice CONTINUOUS INNOVATION environment—combining professional autonomy with Facilitating intraorganizational learning. Kaiser group accountability—is a positive and important fac- Permanente promotes cross-learning among sites and tor in recruiting new physicians. regions through its in-house Permanente Journal Physician leaders believe that the compensation (a recent compilation from the journal identified 34 system is not the primary motivator of performance but clinical practice innovations, with outcome results that it must be aligned with a leadership strategy that and actions for adoption29), annual innovation 12T he  C ommonwealth F und awards and site visits, learning collaborations and organization. This effort includes an annual videocon- workshops, and systemwide resources such as the ference to review the latest evidence, update and refine Permanente Federation and the Kaiser Permanente the guideline (such as by adding a risk-assessment tool Care Management Institute.30 The Care Management to target treatment to those most likely to benefit), and Institute: share best practices. Other Kaiser Permanente regions have adopted the Healthy Bones program or have • convenes interregional working groups of clini- developed similar programs to improve osteoporosis cal experts to develop evidence-based guidelines testing and management.32 “I always come away from (disseminated through the EHR) the meeting knowing more than I came with,” said • offers model care management programs for orthopedic surgeon Richard Dell, M.D. adoption regionally The Healthy Bones team is working with the National Osteoporosis Foundation and the American • develops tools such as health risk assessments Orthopedic Association to spread the word about how • investigates the causes of interregional varia- effective osteoporosis disease management programs tions to identify best practices associated with can be in identifying, risk-stratifying, treating, and better patient outcomes tracking patients at risk for osteoporosis and fractures. Dell estimates that if the Healthy Bones approach were To facilitate local adoption of innovations, med- widely adopted and achieved a 25 percent reduction ical groups identify local clinical champions who are in the rate of hip fractures nationally, it would prevent given resources and tools to educate and engage their 75,000 hip fractures in the United States each year.33 colleagues in making changes to improve practice and outcomes for patients. Developing improved modes of care delivery. The 21st The development of an osteoporosis disease Century Care Collaborative is using KP HealthConnect management program offers an example of this pro- to develop innovations that will transform the ability cess. Responding to evidence that many bone frac- of primary care teams to improve patient care deliv- tures can be prevented, orthopedic surgeons in Kaiser ery and member experience while also promoting a Permanente’s Southern California region led multi- sustainable work environment for clinicians and staff. disciplinary teams in each of the region’s 11 medical A prototype change package—developed from the centers to institute a “Healthy Bones” program for experience of several pilot-test sites—is being spread individuals at risk of osteoporosis and fractures. Care regionally using a flexible approach that lets facili- managers, primary care physicians, and surgeons use ties and teams test elements to determine what works reports generated from the EHR to identify at-risk best in their circumstances. Principles and examples patients and provide them with education, screening, include: treatment, and monitoring as needed. The program has led to a 37 percent reduction in the rate of hip fractures 1. Understand the needs of your population: treated in the region’s medical centers, including a 60 Design the work and build the care team to percent reduction in the best-performing center.31 The meet the needs, e.g., maximize team roles and plan ranks first among Medicare plans nationally on optimize team communication. NCQA’s measure of osteoporosis management. 2. Develop relationship-based care and Under the auspices of the Care Management demonstrate that we know members, e.g., Institute, the region’s orthopedic surgeons joined convene member councils, complete with experts from other Kaiser Permanente regions after-visit summaries. to develop a national clinical practice guideline to standardize osteoporosis management across the K aiser P ermanente : B ridging the Q uality D ivide 13 3. Provide alternatives to traditional office visits, in patients for 12 months, and seven others reported e.g., offer telephone visits and group visits, use only one such infection in the past 12 months. In the secure messaging. Northern California region, core clinical performance 4. Embrace total panel ownership, e.g., conduct measures improved across all hospitals (ranging from outreach to patients with chronic conditions, 4% for heart attack care to 10% for pneumonia care) follow up with patients on new medicines. between 2006 and 2008. The region’s standardized 5. Engage members in collaborative care plan- mortality ratio for heart-attack patients was 27 percent ning, e.g., use goal sheet with diabetic patients, below the national Medicare average in 2008.36 convene chronic care support groups. Over the last several years, Kaiser Permanente has developed and implemented a multipronged approach These changes have synergistic effects. For to handling the disclosure of medical errors. The orga- example, replacing face-to-face visits with telephone nization’s philosophy of disclosure and accountability visits saves time and increases convenience for mem- is encapsulated in the following principles: bers. It also frees time for the care team to conduct proactive panel-management activities, address urgent- • Care for the patient care needs, and look for other opportunities to make • Communicate about unanticipated things easier for patients, such as by calling those on adverse outcomes the appointment schedule to resolve problems over the phone. Pilot sites reported improved quality and • Report to appropriate parties increased satisfaction for members and staff.34 • Check the medical record In 2006, Kaiser Permanente established the • Follow up and provide closure Garfield Innovation Center, a 37,000-square-foot learn- ing laboratory that supports the simulation, prototyp- • Support the patient care team ing, and evaluation of innovations to improve health Physicians receive training on how to have care delivery. Recent projects have prototyped ideas open conversations with patients and families regard- for improving exam room design, reenacted how rapid- ing adverse events and medical errors. “Situation- response teams function to identify best care practices, management teams” of trusted individuals within each and evaluated technologies for patient home monitor- medical center provide counseling and support to ing.35 providers as needed. A health care ombudsman, avail- able in most hospitals, acts as a certified health care Improving care in the inpatient setting. Kaiser mediator to facilitate communication and satisfactory Foundation Hospitals have identified a set of strategic outcomes between the care system and patients and priorities to attain the status of World Class Hospitals their families. Kaiser reports that patients and staff by 2011. Hospitals are engaged in collaborative learn- have expressed positive feedback regarding their inter- ing to promote consistently high clinical performance actions with the ombudsman.37 and to prevent adverse events such as hospital-acquired infections, pressure ulcers (“bed sores”), and patient Pursuing advances in medicine. In Northern falls using rapid-change interventions and “bundles” of California, Kaiser Permanente’s Division of Research evidence-based practices, with performance feedback conducts epidemiologic and health services research to hold leaders accountable for results. to improve the health and medical care of members As of October 2008, eight Kaiser hospitals and the population at large. A major current project reported that their intensive care units had avoided is assembling one of the world’s largest biobanks of any central-line-associated bloodstream infections genetic, environmental, and health data. The biobank 14T he  C ommonwealth F und will enable research on the causes of diseases that center in 2006 was better than the best-performing cen- eventually may lead to advances in diagnosis, treat- ter in 1999. ment, and prevention. Almost 400,000 Northern To promote convenient access to care and infor- California members have volunteered to participate mation—and help reduce demand on the emergency in the program by completing a health survey and are department—the region offers multiple “entry points” being asked to contribute saliva samples for DNA including the following: analysis.38 • call centers that offer one point of contact for Improving efficiency. Innovations also focus on routine plan information, primary care appoint- improving the efficiency of operations and cost-effec- ment scheduling, and 24-hour nurse advice tiveness of care. For example, Kaiser Permanente’s • the ability to “self-book” appointments through size and integrated structure (almost all health plan the phone or the Web (patients who book their members use Kaiser Permanente pharmacies) allowed appointments online are more likely to keep the Northern California region to offer market share- them39) based purchasing guarantees to generic pharmaceuti- cal suppliers. Permanente physicians are encouraged • after-hours urgent-care appointments at selected to follow clinical guidelines, developed by expert locations (some medical centers offer walk-in physician peers and clinical pharmacists, to prescribe treatment for minor injuries) preferred generic equivalents to brand-name drugs • the option of scheduling a telephone visit with whenever appropriate. This strategy enabled the plan in the patient’s primary care physician for condi- 2005 to realize annual cost savings of more than $150 tions amenable to resolution over the phone million from the use of generic cholesterol-lowering • electronic messaging with the primary care team drugs, for example, as compared with community pre- for nonurgent matters, and with a specialist that scribing patterns for such drugs. the patient has consulted for up to a year after the visit EASY ACCESS TO APPROPRIATE CARE The Northern California region recently undertook an To offer timely and convenient appointments, initiative to improve patient-rated access and service the region aims for its call centers to book an appoint- on five targeted “imperatives of personal care.” These ment with the patient’s designated primary care include: 1) patients have a personal primary care physician on a date and time that is acceptable to the physician; 2) they are able to see that physician; 3) patient in one call (“first contact scheduling”), a goal callers have a short telephone wait; 4) they receive that it attains about 85 percent of the time, according timely appointments; and 5) patients have a superior to Donald Dyson, M.D., associate executive direc- care experience. (Primary care physicians include tor of The Permanente Medical Group of Northern general internists, family practitioners, pediatricians, California. When the teleservice representative cannot and obstetrician/gynecologists.) offer an appointment that is acceptable to a patient, he Regional leaders determined operational tactics or she sends an electronic notification to the patient’s associated with high patient ratings, set operational primary care office, which contacts the patient to find targets to meet them (such as having sufficient primary an acceptable time or, when appropriate, offer a tele- care physicians at each location with open panels to phone consultation with the doctor. meet demand), and monitored performance. As a result Teleservice representatives (who receive of this effort, patient satisfaction scores increased training, coaching, and monitoring on the job) use regionwide, so much so that the worst-performing physician-created scripts to offer appointments in a K aiser P ermanente : B ridging the Q uality D ivide 15 medically acceptable time frame based on the patient’s KP HealthConnect has been designed to actual- chief complaint. Patients with urgent problems are ize the philosophy that “the home and other personal scheduled to see a physician on the same or next day, settings will be the locale of choice for many health while those with routine or chronic issues are sched- care services.”41 Family members can act as proxy uled more flexibly. Those who indicate emergent prob- users for children or other patients who do not use lems (such as chest pain) are immediately transferred online services. One in 10 online users surveyed in the to an advice nurse, who can consult with a physician Northwest region indicated that they would not have if necessary to recommend an appropriate course of contacted their provider if they couldn’t send elec- action such as going to the emergency department. tronic messages, suggesting that the Web portal may This approach has elements in common with help to address otherwise unmet needs.42 The standard the same-day appointment scheduling model known for replying to electronic messages is 48 hours. In the as “advanced access,” which was originally developed Colorado region, physicians are encouraged to respond at a Northern California Kaiser Permanente clinic, in within 24 hours, a goal they reportedly meet more than that it seeks to balance the supply of and demand for 90 percent of the time.43 physician appointments and promote patient satisfac- As an alternative to the traditional physician tion with care. About four of five Northern California visit, patients with chronic illnesses can elect to par- Kaiser Permanente members (82%) report getting ticipate in a variety of scheduled and drop-in group appointments and care quickly, ranking the region medical visits in many areas. Group visits offer the second among nine California health plans in the opportunity to meet regularly with a multidisciplinary Consumer Assessment of Healthcare Providers and care team (which may include a health educator and Systems (CAHPS) survey.40 pharmacist in addition to the physician) while build- For specialty care, the Northern California ing social support with peers. In a controlled trial region has set a goal that 75 percent of patients will conducted in Colorado among older, chronically be able to see a specialist within two weeks of a refer- ill patients, those who attended 90-minute monthly ral from their primary care physician. Referrals are “Cooperative Health Care Clinics” had fewer hospital- made electronically using KP HealthConnect and can izations and emergency visits and lower overall costs be requested by patients over the phone. Some medi- of care than usual-care patients. Group-visit partici- cal centers have “roving” dermatologists who can be pants also reported better quality of life and ability to consulted directly during primary care visits, so that manage their health, and higher satisfaction with their patients need not schedule a separate appointment. In physician.44 other locations, dermatologists can be consulted elec- Through these kinds of access initiatives and tronically through audiovisual tele-health connections. related care management, information technology, and Kaiser plans to offer scheduled online encoun- process improvements, Northern California members’ ters or e-visits in the future for patients with the neces- use of the emergency department (ED) declined by sary audiovisual technology (e.g., Webcam). In a pilot almost one-third over the course of 11 years, from a test at one medical center, patients can attach a digital rate of 300 visits per 1,000 adults in 1997 to 205 visits photograph to electronic messages to help their physi- per 1,000 in 2008 (Exhibit 9). Philip Madvig, M.D., cian determine the nature of their problem. For exam- associate executive director of the medical group, ple, a physician could view a photo of a child’s rash credits the integrated nature of the delivery system to determine that it is the chicken pox and thus avoid with laying the foundation that has made this kind of a visit that would expose other children to infection in improvement possible. the physician’s office. 16T he  C ommonwealth F und Offering Culturally Competent Care. Kaiser “Recognizing Innovation in Multicultural Health Care” Permanente’s Personalized Care Model encompasses award as models for other health plans. The Qualified a commitment to providing culturally competent care Bilingual Staff model curriculum has been used to and to working aggressively toward eliminating health train more than 3,000 staff in Northern California to disparities. Its Institute for Culturally Competent Care enhance their linguistic competency in serving patients develops tools, training, and educational resources who speak languages other than English.46 The Health to help accomplish these goals. The Institute guides Care Interpreter Certificate Program, developed by the work of nine Centers of Excellence in Culturally Kaiser Permanente and offered in conjunction with the Competent Care, located in several regions, which City College of San Francisco, has trained more than tailor services to meet the unique health care needs 1,000 students to address gaps in the training and avail- of diverse population groups including African ability of qualified interpreters.47 Americans, Armenians, Latinos, people with disabili- ties, and women.45 RECOGNITION OF PERFORMANCE Several California medical centers offer culture- In addition to the results of the specific interventions specific patient-care modules (Chinese, Spanish/ described above, Kaiser Permanente has achieved nota- Latino, and Vietnamese) where patients can commu- ble results on selected externally reported performance nicate in their native language with a bilingual care indicators and has received recognition for its perfor- team oriented to their cultural norms. Anne Tang, mance on several national benchmarking or award pro- M.D., chief of the Bilingual Chinese Module at the San grams (Exhibit 10). Francisco Medical Center, described how establishing The California Office of the Patient Advocate’s cultural rapport can be critical to effective treatment, 2008 Healthcare Quality Report Card gave Kaiser for example, by allowing members to feel comfortable Permanente’s Northern and Southern California disclosing the use of alternative medicines such regions the highest overall ratings among eight large as herbal blood thinners that can interact with antico- health maintenance organizations in the state. Both agulation treatment. regions received four-star “excellent” ratings for clini- Two Kaiser Permanente programs have earned cal quality (the only plans to do so) and three-star the National Committee for Quality Assurance’s “good” ratings for consumer experience (two other Exhibit 9. Kaiser Permanente Northern California: Trend in Emergency Department Use Emergency department visits per 1,000 adults 350 300 250 200 150 100 50 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 * Data from 2006 are unavailable. Source: Kaiser Permanente. K aiser P ermanente : B ridging the Q uality D ivide 17 Exhibit 10. Selected Externally Reported Results and Recognition for Kaiser Permanente of Northern California and Colorado* Inpatient Care Quality51 Four-topic clinical composite (24 measures): Eight of 14 Northern California Kaiser hospitals (CMS Hospital Compare evaluated ranked in the top quartile, and three of these in the top decile, of U.S. hospitals Jan.–Dec. 2007) evaluated. Heart attack treatment (8 measures): Eight of 14 Northern California Kaiser hospitals evaluated ranked in the top quartile, and two of these in the top decile, of U.S. hospitals evaluated. Heart failure treatment (4 measures): Seven of 15 Northern California Kaiser hospitals evalu- ated ranked in the top quartile, and three of these in the top decile, of U.S. hospitals evaluated. Pneumonia treatment (7 measures): Four of 15 Northern California Kaiser hospitals evaluated ranked in the top quartile, and one of these in the top decile, of U.S. hospitals evaluated. Surgical care improvement (5 measures): Ten of 15 Northern California Kaiser hospitals evalu- ated ranked in the top quartile, and four of these in the top decile, of U.S. hospitals evaluated. Ambulatory Care Clinical quality (34 measures): Kaiser Health Plan of Colorado ranked in the top quartile of Quality commercial health plans nationally or regionally on 26 measures, 23 of which were in the top (NCQA Quality decile. Kaiser Health Plan of Northern California ranked in the top quartile of commercial health Compass 2008) plans nationally or regionally on 27 measures, 23 of which were in the top decile. Patient experience (9 measures): Kaiser Health Plan of Colorado ranked in the top decile of commercial health plans nationally or regionally on one measure. Kaiser Health Plan of North- ern California ranked in the top quartile of commercial health plans nationally or regionally on three measures, one of which was in the top decile. National Recognition National Research Corporation’s Consumer Choice Award: Kaiser Foundation Hospital–Santa and Ratings Rosa in 2006/2007; Kaiser Foundation Hospital–Fremont in 2007/2008; Kaiser Permanente Vallejo Medical Center in 2003/2004–2007/2008. National Committee for Quality Assurance: Health Plan Excellent Accreditation (both regions); Quality Plus Distinction in Member Connections (Northern California); Disease Management Program Design Certification (Care Management Institute); Physician Practice Connections Recognition Program (Northern California); Innovation in Multicultural Health Care Award. US News & World Report Best Health Plans: Kaiser Health Plan of Colorado ranked among the top 50 commercial health plans in 2008 and among the top 25 Medicare plans in 2005– 2008; Kaiser Health Plan of Northern California ranked among the top 50 commercial plans in 2006 and 2008 and among the top 25 Medicare plans in 2006–2008. JD Power and Associates National Health Insurance Plan Study: Kaiser Health Plan of Colo- rado and Kaiser Health Plan of Northern California ranked in the top quartile of 104 large commercial health plans evaluated in 2008 and in the top decile of 128 such plans evaluated in 2009, and ranked first in their state among four and six plans evaluated in Colorado in 2008 and 2009, respectively, and among seven plans evaluated in California in both years. National Business Coalition on Health eValue8: Kaiser Health Plan of Northern California was the highest-performing Benchmark Plan for behavioral health in 2007. Health Information Management Systems Society (HIMSS) Analytics Stage 7 Award: 11 North- ern California Kaiser hospitals are among 15 U.S. hospitals recognized for implementing an integrated EHR to achieve a paperless environment and the ability to share, warehouse, and analyze clinical data for improved decision support and care delivery. *See the Series Overview, Findings, and Methods for analytic methodology and explanation of performance recognition. CMS = Centers for Medicare and Medicaid Services; NCQA = National Committee for Quality Assurance (Quality Compass 2008 represents the 2007 measurement year); HEDIS = Healthcare Effectiveness Data and Information Set. 18T he  C ommonwealth F und plans also received three stars in this category).48 The in accessing services after hours, and were more likely Permanente Medical Group ranked in the top 20 per- to be “somewhat” or “very” satisfied with their health cent of California medical groups evaluated on clinical benefits compared with other patients.52 quality, patient satisfaction, and health information An analysis of hospital use at the end of life technology by the Integrated Healthcare Association, a among older Californians with chronic illness found coalition of stakeholders that rewards the performance that HMO (health maintenance organization) patients of physician groups in California.49 treated in Kaiser Foundation Hospitals had similar In a 2002 survey of California physicians overall use but much less regional variation in use than conducted by the University of California, San HMO patients admitted to non-Kaiser hospitals in the Francisco, Center for the Health Professions, Kaiser state. (HMO patients generally had lower hospital use Permanente physicians were more likely to report that and less regional variation in use than patients with participating in a medical group is an advantage in fee-for-service coverage.) Author Laurence Baker practicing medicine; that they receive incentives based wrote: “One possible interpretation of these results on quality of care and patient satisfaction; that practice is that greater care integration and hospital capac- profile information is useful; that they work with ity [management] play important roles in reducing nonphysician clinicians (suggesting interdisciplinary regional variations of hospital use.”53 teamwork); and that disease management programs are The identification of areas of excellence does offered to their patients.50 not mean that Kaiser Permanente has achieved perfec- In a recent survey conducted for the California tion. Its model works well most of the time but occa- HealthCare Foundation, patients of Kaiser Permanente sionally fails to live up to its promise. For example, in reported higher measures of physician-directed health 2006, the Northern California region closed a fledgling management services, collaborative health manage- kidney transplant program in San Francisco following ment goal-setting, and reminders for preventive or news accounts that patients faced prolonged waiting follow-up care compared with patients seen in other times in the program.54 The State of California fined settings of care in California (Exhibit 11). Kaiser the health plan $2 million for lapses in program over- patients were also less likely to report difficulties in sight and another $2 million after a follow-up investi- securing an appointment for the same or next day or gation found that the plan had failed to establish and Exhibit 11. Kaiser Permanente Compared with Other California Practice Sites on Selected Managed and Preventive Care Services and Access to Care Percent of adult respondents with chronic conditions Solo practice Group practice Clinic/VA/Other Kaiser Permanente 80 70 66 60 55 55 53 51 54 49 52 38 42 40 36 20 0 Receives health management Receives reminders when due Finds it somewhat/very difficult services from physician* for preventive or follow-up care to get after-hours services (lower is better) *Health management services Includes: patient education materials, phone calls for advising care, prescription/refill reminders, home monitoring devices, and written plans for managing care. Source: California HealthCare Foundation, Living with Chronic Illness: Californians’ Perspectives on Cost and Coordination of Care (Oakland: California HealthCare Foundation, 2008). Survey of 2,745 adult respondents with chronic conditions, conducted online Nov. 2–19, 2007, using the Harris Interactive public panel. K aiser P ermanente : B ridging the Q uality D ivide 19 maintain adequate procedures for reviewing quality of a primary care physician’s patients use it and as the of care in several medical centers.55 The health plan physician incorporates it into patient care manage- implemented a correction plan to address identified ment. Permanente physicians would never go back to deficiencies and agreed to future audits of its progress. the old way of working now that they see how these Kaiser Permanente’s track record suggests that the technologies improve the patient care experience, said organization will learn from such missteps and con- Bernadette Loftus, M.D., associate executive director tinue to improve its performance over time. of The Permanente Medical Group. Kaiser Permanente’s innovative model of care INSIGHTS AND LESSONS LEARNED delivery can generate controversy as it challenges Kaiser Permanente illustrates how a prepaid, integrated traditional norms, though the outcome can be posi- multispecialty group practice can manage population tive. During the organization’s early years, the medical health through the confluence of supportive organi- community opposed prepaid group practice as a threat zational structure, mission, leadership, and culture. to traditional medicine. When Permanente physicians Although Kaiser Permanente is actually three coopera- were denied staff privileges in community hospitals, tive entities that engage in shared decision-making, Kaiser built its own hospitals to care for its members. it functions as an integrated whole and appears from This approach turned out to confer an advantage on the outside to be a single organization. Mutual inter- the organization, allowing it to closely manage its dependency means that neither the medical group nor resources and achieve consistent results across its the health plan can afford to let the other fail. Each service area. must maintain patient trust and quality of care, while The care delivery model has been adapted by at the same time maintaining fiscal responsibility and Kaiser in its regions outside California, where full responding to market demands. integration does not exist because Kaiser does not own Coordination of care is enhanced by the com- hospitals. In those regions the local organization seeks bination of a closely knit multispecialty group and a to develop good working relationships with contracted common information system that makes it possible to hospitals to facilitate care management, but lack of share information seamlessly across specialties and electronic linkages can impose barriers to the flow of settings. Aligned incentives and group accountabil- information. Integration is enhanced in a contracted ity appear to reduce internal tension between clinical hospital in Colorado that shares a common EHR, mak- disciplines within the medical group, enabling them ing it possible to link inpatient and outpatient infor- to cooperate in achieving group goals such as cost- mation on Kaiser members treated there. To better efficient deployment and use of radiological imaging compete in its marketplace, the Colorado region also technology. In a recent account of Kaiser Permanente’s recently began offering its members the option of self- EHR adoption process, author Charles Kenney referring to specialists. reported that physician involvement in the selection The Permanente Medical Groups aren’t content of the technology vendor was critical to its successful to simply pay everyone a salary and hope for the best implementation.56 outcomes. Managing the culture appears to be a key Adopting information technology entails some element in producing a high-functioning group. Kaiser time trade-offs to achieve promised results. While a CEO George Halvorson cites the 1990s turnaround well-implemented EHR enhances physicians’ ability to experience as one proof that organizational culture can deliver high-quality medicine and meet patients’ needs, be changed to emphasize key values, such as closely it requires more of their time for information record- adhering to clinical evidence when treating patients. ing and management. Likewise, secure messaging with Physician leader Sharon Levine put it this way: “Thirty patients may increase physicians’ workload initially, percent of driving performance is science: Identify the but eventually can reduce face-to-face visits as more right thing to do. Seventy percent is sociology: Make 20T he  C ommonwealth F und the right thing happen, and make the right thing easy to investment of $4 billion for KP HealthConnect and do.” While there is a strong expectation for following spends about 3 percent of annual revenue on its infor- standards on clinical matters, physicians are afforded mation technology budget. The medical groups also greater autonomy in operational matters, such as invest in training physicians, which entailed some tem- whether to conduct telephone or group visits porary loss in productivity during EHR adoption. with patients. Physicians and staff who led the site visit for The Commonwealth Fund exhibited a discernible “Thirty percent of driving performance is science: optimism and pride of purpose in their clinical prac- Identify the right thing to do. Seventy percent is tice and in the organization’s work. They described a sociology: Make the right thing happen, and make culture in which everyone is expected to continually the right thing easy to do.” improve performance. Assuming that this attitude is Sharon Levine, M.D., associate executive widespread within the workforce, the organization director, The Permanente Medical Group. appears to engender a valuable commitment to its mis- sion. Evidence to support this observation includes the low turnover rate among physicians (4%–5% in the The Kaiser Permanente model of integrated first three years after recruitment and less than 1.5% group practice has the advantage of having evolved thereafter) and survey results indicating increasing over seven decades, but it may not be easy to replicate physician satisfaction and higher staff ratings of orga- today. During the 1980s and 1990s, Kaiser sought to nizational quality during the past few years. expand in several new regions, but only two (Georgia Kaiser Permanente’s experience also suggests and the Mid-Atlantic) proved successful. Researchers that prepaid group practice alone may not be enough who studied the North Carolina experience found that a to achieve the highest performance without market combination of political, economic, and organizational pressure and transparency. Until the 1990s, Kaiser factors contributed to the plan’s withdrawal from that Permanente enjoyed a 15–20 percent price advantage state. They concluded that realizing the potential of this in the insurance market due to the principles of its model in new markets requires a “conjuncture of sev- model, but its competitors learned to achieve similar eral supportive conditions,” such as gaining a critical gains in part by emulating and adapting its strategies. mass of members to support the delivery of a full scope Financial losses sustained in the late 1990s, along with of services that can be internalized within the multi- the advent of public performance reporting in combi- specialty group. Doing so may depend in large part on nation with unblinded internal performance feedback whether purchasers offer and reward consumers for within the medical group, acted as a wake-up call that selecting better-value options.57 energized the organization to demonstrate the potential Whether or not the Kaiser Permanente model of its model by making a stronger push for innovation can be replicated in its entirety, it offers a valuable and quality. source of inspiration and experience as a “learning Today the plan seeks to differentiate itself on laboratory” for the development of strategies, tech- overall value with a competitive price point in the niques, and innovations that may be transferable to marketplace. The Northern California region has main- other settings—not only other multispecialty groups, tained a consistent cost-growth trend of about 6 percent but also traditional practices. For example, many per year over the past 10 years, although premiums medical practices and organizations nationwide have have risen somewhat more to fund infrastructure adopted the “advanced access” model of patient sched- improvements that are expected to deliver increasing uling pioneered by Mark Murray, M.D., and Catherine value over time. The health plan has made a capital K aiser P ermanente : B ridging the Q uality D ivide 21 Tantau, R.N., primary care team leaders at the Kaiser medical practice to assure patient satisfaction and loy- Permanente clinic in Roseville, California.58 alty and to help promote better health outcomes.60 Some innovations that appear rooted in Kaiser’s Summarizing Kaiser Permanente’s current strat- organizational context may be seen in a different light egy and experience, CEO George Halvorson said that should purchasers adopt payment reforms that promote organizations wishing to achieve excellence require an coordination of care.59 For example, Kaiser’s use of overarching agenda to: 1) focus attention on the most telephonic and electronic patient encounters may not important conditions driving overall costs; seem desirable to medical practices paid on a fee-for- 2) provide goal-oriented tools to analyze population service basis, which encourages them to maximize data, proactively identify patients in need of interven- face-to-face encounters, but may be more attractive tion, and support systematic process improvements; under a payment scheme that rewards efficient prac- and 3) create a culture in which patients and profes- tice. Should consumers come to demand them, these sionals collaborate to improve health. tools may come to be seen as necessary adjuncts to For a complete list of case studies in this series, along with an introduction and description of methods, see Organizing for Higher Performance: Case Studies of Organized Health Care Delivery Systems— Series Overview, Findings, and Methods, is available at www.commonwealthfund.org. 22T he  C ommonwealth F und N otes 6 J. H. Cochran, Statement on Behalf of the Kaiser Permanente Medical Care Program Before the 1 T. Shih, K. Davis, S. Schoenbaum, A. Gauthier, Committee on Health, Education, Labor, and Pen- R. Nuzum, and D. McCarthy, Organizing the U.S. sions (Washington, D.C.: United States Senate, Jan. Health Care Delivery System for High Performance 15, 2009). (New York: The Commonwealth Fund Commission 7 As of April 2008, approximately 3 million members on a High Performance Health System, Aug. 2008). had registered to access these My Health Manager 2 Information about Kaiser Permanente was synthe- features. Secure electronic messaging takes place in sized in part from a presentation by CEO George an authenticated/encrypted Web environment behind Halvorson to a Commonwealth Fund Commission an enterprise-level firewall. on a High Performance Health Care System meeting 8 E. Montalbano, “Microsoft, Kaiser Pilot Integra- in San Francisco, and from the Commission’s site tion of E-health Systems,” ABC News/IDG News visit to the Kaiser Permanente San Francisco Medi- Service, June 9, 2008, http://abcnews.go.com/Tech- cal Center in March 2007. Additional information nology/PCWorld/story?id=5030248. was obtained from presentations, telephone inter- views, or e-mail communications with the individu- 9 For a description of how the EHR helps improve als named in the acknowledgments; from informa- cancer treatment, see P. J. Wallace, “Reshaping Can- tion and documents available on the organization’s cer Learning Through the Use of Health Information Web site (www.kp.org) and from regulatory filings; Technology,” Health Affairs Web Exclusive, Jan. and from other presentations and publications cited 2007 26(2):w169–w177. below. 10 J. Hsu, J. Huang, V. Fung et al., “Health Informa- 3 A summary of findings from all case studies in the tion Technology and Physician-Patient Interactions: series can be found in D. McCarthy and K. Mueller, Impact of Computers on Communication During Organizing for Higher Performance: Case Studies Outpatient Primary Care Visits,” Journal of the of Organized Delivery Systems. Series Overview, American Medical Informatics Society, Aug. 2005 Findings, and Methods (New York: The Common- 12(4):474–80. wealth Fund, 2009). 11 J. Derman, T. Garrido, L. Radler et al., “Impact of 4 For examples, see A. C. Enthoven and L. A. Tollen, KP.org Personal Health Record with Secure Mes- “Epilogue,” in Toward a 21st Century Health Sys- saging on Office Visits and Patients’ Calls,” presen- tem, edited by A. C. Enthoven and L. A. Tollen (San tation at the National Forum on Quality Improve- Francisco: Jossey-Bass, 2004). ment in Healthcare, Dec. 10, 2008. 5 The Colorado region developed an EHR in col- 12 Y. Y. Zhou, T. Garrido, H. L. Chin et al., “Patient laboration with IBM Corporation that was fully Access to an Electronic Health Record with Secure functional by 1997. Physicians in the Northwest Messaging: Impact on Primary Care Utilization,” region had access to an EHR (from Epic Systems American Journal of Managed Care, July 2007 Corp.) starting in 1994; exam room computers 13(7):418–24. were installed in 2001. Kaiser began rolling out the Colorado EHR to other regions early in the decade but reevaluated that decision and, through a process that actively involved clinicians, selected the Epic system as a better fit for its needs. For more on this topic, see C. Kenney, “Kaiser Permanente and the Future of Health Care,” in The Best Practice: How the New Quality Movement Is Transforming Medicine (Philadelphia: PublicAffairs/Perseus Book Group, 2008). K aiser P ermanente : B ridging the Q uality D ivide 23 13 C. Chen, T. Garrido, D. Chock et al., “The 19 Appropriate receipt of prescription medications Kaiser Permanente Electronic Health Record: means that the patient was assessed, did not have Transforming and Streamlining Modalities of Care,” contraindications to the drug, was prescribed the Health Affairs 2009 28(2):323–33. Similar though drug, and filled the prescription at the pharmacy. more modest effects were seen in the Colorado and The drugs included lipid-lowering medications, Northwest regions after they implemented legacy ACE inhibitors, and beta-blockers. EHRs. See T. Garrido, L. Jamieson, Y. Zhou et al., “Effect of Electronic Health Records in Ambulatory 20 For more information on this model, see: M. Butler, Care: Retrospective, Serial, Cross Sectional R. L. Kane, D. McAlpine et al., “Integration of Study,” British Medical Journal, March 2005 Mental Health/Substance Abuse and Primary Care,” 330(7491):581–85. Evidence Report/Technology Assessment No. 173 (Rockville, Md.: Agency for Healthcare Research 14 B. G. Sandhoff, S. Kuka, J. Rasmussen et al., “Col- and Quality, Oct. 2008). laborative Cardiac Care Service: A Multidisciplinary Approach to Caring for Patients with Coronary 21 AHRQ Health Care Innovations Exchange, “Post- Artery Disease,” The Permanente Journal, Sum- Discharge Telephone Follow-Up with Chronic Dis- mer 2008 12(3):4–11; http://xnet.kp.org/newscenter/ ease Patients Reduces Hospitalizations, Emergency pressreleases/nat/2009/032709ahrstudy.html. Department Visits, and Costs,” Oct. 2008, http:// www.innovations.ahrq.gov/content.aspx?id=2300. 15 J. A. Merenich, T. R. Lousberg, S. H. Brennan et al., “Optimizing Treatment of Dyslipidemia in Patients 22 AHRQ Health Care Innovations Exchange, “In- with Coronary Artery Disease in the Managed Care novation Profile: Automated Pharmacy Alerts Environment,” American Journal of Cardiology, Followed by Pharmacist-Physician Collaboration 2000 85:36A–42A; K. J. Olson, J. Rasmussen, B. G. Reduce Inappropriate Prescriptions Among Elderly Sandhoff et al., “Lipid Management in Patients with Outpatients,” April 2008, http://www.innovations. Coronary Artery Disease by a Clinical Pharmacy ahrq.gov/content.aspx?id=1780. Service in a Group Model Health Maintenance 23 D. M. Witt, M. A. Sadler, R. L. Shanahan et al., “Ef- Organization,” Archives of Internal Medicine, 2005 fect of a Centralized Clinical Pharmacy Anticoagu- 165:49–54. lation Service on the Outcomes of Anticoagulation 16 National Committee for Quality Assurance, Quality Therapy,” Chest, May 2005 127:1515–22. Compass 2008 (Washington, D.C.: NCQA, 2008). 24 B. Fireman, J. Bartlett, and J. Selby, “Can Disease 17 Management Reduce Health Care Costs by Im- J. A. Merenich, K. L. Olson, T. Delate et al., “Mortality Reduction Benefits of a Comprehensive proving Quality?” Health Affairs, Nov./Dec. 2004 Cardiac Care Program for Patients with Occlusive 23(6):63–75. Coronary Artery Disease,” Pharmacotherapy, 25 F. J. Crosson and P. Madvig, “Does Population Oct. 2007 27(10):1370–78. The average duration Management of Chronic Disease Lead to Lower of follow-up in the study was 3.6 years after Costs of Care?” Health Affairs, Nov./Dec. 2004 hospitalization. 23(6):76–78. 18 J. Rasmussen and S. Kuca, “Collaborative Cardiac 26 For more on group culture and physician leader- Care: Teams Plus Technology Equals Quality,” pre- ship at Kaiser Permanente, see: F. J. Crosson, A. J. sentation at the Alliance for Health Reform briefing: Weiland, and R. A. Berenson, “Group Responsibil- Reforming the Health Care Delivery System, March ity as Key to Accountability in Medicine,” in A.C. 27, 2009; http://www.allhealth.org/briefing_detail. Enthoven and L.A. Tollen (eds.), Toward a 21st asp?bi=151. Century Health System: The Contributions and Promise of Prepaid Group Practice (San Francisco: Jossey-Bass, 2004). 24T he  C ommonwealth F und 27 S. E. Eaton, T. A. Kochan, R. B. McKersie, The Kai- 35 http://xnet.kp.org/innovationcenter/index.htm. ser Permanente Labor Management Partnership: 36 M. Skeath and J. Nunes, “Collaborative Model: The First Five Years (Cambridge: Massachusetts Creating Breakthrough Performance,” presentation Institute of Technology, Sloan School of Manage- at the National Forum on Quality Improvement in ment, 2003). Healthcare, Dec. 10, 2008. 28 T. A. Kochan, P. S. Adler, R. B. McKersie et al., 37 E. Shapiro, “Disclosing Medical Errors: Best Prac- “The Potential and Precariousness of Partnership: tices from the Leading Edge,” March 2008, http:// The Case of the Kaiser Permanente Labor Man- www.ihi.org/IHI/Topics/PatientSafety/SafetyGen- agement Partnership,” Industrial Relations, 2008 eral/Literature/DisclosingMedicalErrorsBestPrac- 47(1):36–65. ticesLeadingEdge.htm. 29 “Clinical Practice Innovations: 2006–2008,” The 38 http://www.dor.kaiser.org/studies/rpgeh/index.html. Permanente Journal, http://xnet.kp.org/permanente- journal/CPIbooklet.pdf. 39 L. Beckman, “Electronic Health Records: Innovat- ing in Partnership,” presentation at the Partnership 30 P. Wallace, “The Care Management Institute: for Quality Care Summit, March 19, 2008. Making the Right Thing Easier to Do,” Permanente Journal, Spring 2005 9(2):56–7; H. S. Pettay, 40 California Office of the Patient Advocate, 2008 B. Branthaver, K. Cristobal et al., “The Care Healthcare Quality Report Card, http://www.opa. Management Institute: Harvesting Innovation, ca.gov/report_card/HMOmeasure.aspx?Category=- Maximizing Transfer,” Permanente Journal, Fall CAHPS&Topic=GettingDoctorsAndCare&Measure 2005 9(4):37–39. =GettingAppointmentsAndCareQuickly. 31 R. Dell, D. Greene, S. R. Schelkun et al., “Os- 41 Francis, 21st Century Care Innovation Collaborative. teoporosis Disease Management: The Role of the Orthopaedic Surgeon,” Journal of Bone and Joint 42 C. A. Serrato, S. Retecki, and D. E Schmidt, Surgery, 2008 90(Suppl. 4):188–94. “MyChart—A New Mode of Care Delivery: 2005 Personal Health Link Research Report,” The Perma- 32 For examples of programs in other regions, see: A. nente Journal, Spring 2007 11(2):14–20. C. Feldstein, W. M. Vollmer, D. H. Smith et al., “An Outreach Program Improved Osteoporosis Manage- 43 S. Okie, “Innovation in Primary Care—Staying One ment After a Fracture,” Journal of the American Step Ahead of Burnout,” New England Journal of Geriatrics Society, 2007 55:1464–69; “M. Che, B. Medicine, Nov. 2008 359(22):2305–9. Ettinger, J. Johnston et al., “Fragile Fracture Care 44 J. C. Scott, D. A. Conner, I. Venohr et al., “Ef- Management Program,” The Permanente Journal, fectiveness of a Group Outpatient Visit Model for 2005 9(1):13–15. Chronically Ill Older Health Maintenance Orga- 33 Approximately 300,000 hip fractures occur each nization Members: A 2-Year Randomized Trial year in the United States with estimated treatment of the Cooperative Health Care Clinic,” Journal costs of $18 billion, according to the National Os- of the American Geriatrics Society, Sept. 2004 teoporosis Foundation. 52(9):1463–70; A. Beck, J. Scott, P. Williams et al., “A Randomized Trial of Group Outpatient Visits for 34 H. King, R. Brentari, L. Francis et al., “People Us- Chronically Ill Older HMO Members: the Coopera- ing Technology to Transform Care: The 21st Cen- tive Health Care Clinic,” Journal of the American tury Care Innovation Project,” Permanente Journal, Geriatrics Society, May 1997 45(5):643–44. Winter 2007 11(1):40–44; L. Francis, “The 21st Century Care Innovation Collaborative,” presenta- 45 M. Tervalon, “At a Decade: Centers of Excellence tion to the Alliance for Community Health Plans, in Culturally Competent Care,” Permanente Jour- Sept. 24, 2007, http://www.achp.org/library/down- nal, 2009 13(1):87–91. load.asp?id=7150. K aiser P ermanente : B ridging the Q uality D ivide 25 46 Robert Wood Johnson Foundation, National 53 L. Baker, Same Disease, Different Care: How Health Plan Collaborative Toolkit, “Kaiser Per- Patient Health Coverage Drives Treatment Pat- manente: Qualified Bilingual Staff Model,” Sept. terns in California (Oakland: California HealthCare 2008, http://www.rwjf.org/qualityequality/product. Foundation, 2008). The analysis focused on the jsp?id=34030. last two years of life among non-Medicare patients ages 55–64 and Medicare patients ages 67 years and 47 Robert Wood Johnson Foundation, National Health older with at least one of 13 chronic conditions who Plan Collaborative Toolkit, “Kaiser Permanente: died between 1999 and 2003, adjusting for demo- Health Care Interpreter Certificate Program,” Sept. graphics and related patient characteristics. 2008, http://www.rwjf.org/qualityequality/product. jsp?id=34036. 54 C. Ornstein and T. Weber, “Kaiser Put Kidney Patients at Risk,” Los Angeles Times, May 3, 2006; 48 California Office of the Patient Advocate, 2008 “Kaiser Halts Kidney Venture,” Los Angeles Times, Healthcare Quality Report Card, http://www.opa. May 13, 2006; “U.S. Berates Kaiser over Kidney ca.gov/report_card/hmorating.aspx. Effort,” Los Angeles Times, June 24, 2006. 49 Integrated Healthcare Association Announces 55 T. Weber and C. Ornstein, “Kaiser to Pay Record Pay for Performance Program Results and Award Fine over Kidney Program,” Los Angeles Times, Winners, Oct. 2, 2008, http://www.iha.org/p4pyr6/ Aug. 10, 2006; “State Fines Kaiser Again,” Los An- Top2008%20News%20Release_Final_10_02_08. geles Times, July 26, 2007; Department of Managed pdf. Health Care, Enforcement Matter No. 06-162 and 50 D. R. Rittenhouse, K. Grumbach, E. H. O’Neil No. 07-202 (Sacramento: State of California, Aug. et al., “Physician Organization and Care Man- 11, 2006, and Jul. 30, 2007). agement in California: From Cottage to Kaiser,” 56 Kenney, “Kaiser Permanente and the Future of Health Affairs, Nov./Dec. 2004 23(6):51–62; and Health Care.” K. Grumbach, C. Dower, S. Mutha et al., Califor- nia Physicians 2002: Practice and Perceptions 57 D. P. Gitterman, B. J. Weiner, M. E. Domino et (San Francisco: California Workforce Initiative at al., “The Rise and Fall of a Kaiser Permanente the UCSF Center for the Health Professions, Dec. Expansion Region,” The Milbank Quarterly, 2003 2002). 81(4):567–601. 51 Rankings for CMS Hospital Compare clinical topics 58 M. Murray and C. Tantau, “Same-Day Appoint- (heart attack, heart failure, and pneumonia treatment ments: Exploding the Access Paradigm,” Family and surgical care improvement) were compiled by Practice Management, Sept. 2000 7(8):45–50; D. Island Peer Review Organization for The Common- A. Grandinetti, “You Mean I Can See the Doc- wealth Fund and included hospitals that reported tor Today?” Medical Economics, March 20, 2000 on all measures and recorded at least 30 patients 77(6):102–4, 109, 113–14. in each topic. Only results for Northern California Kaiser Foundation Hospitals that ranked in the top 59 S. Guterman, K. Davis, C. Schoen, and K. Stre- quartile are noted; none ranked in the top quartile mikis, Reforming Provider Payment: Essential on the HCAHPS (Hospital Consumer Assessment of Building Block for Health Reform (New York: The Healthcare Providers and Systems) overall patient Commonwealth Fund, March 2009). rating of care (9 or 10 on a 10-point scale). Results 60 Three of four consumers surveyed in 2008 ex- do not include Antioch Medical Center. The Colo- pressed interest in online connectivity and services rado region does not own hospitals. from their provider. Deloitte Center for Health 52 California HealthCare Foundation, Living with Solutions, 2008 Survey of Health Care Consumers Chronic Illness: Californians’ Perspectives on Cost (Washington, D.C.: Deloitte, Sept. 2008). and Coordination of Care, 2008 (Oakland: Califor- nia HealthCare Foundation, April 2008). 26T he  C ommonwealth F und A bout the A uthors Douglas McCarthy, M.B.A., president of Issues Research, Inc., in Durango, Colorado, is senior research adviser to The Commonwealth Fund. He supports the Commonwealth Fund Commission on a High Performance Health System’s scorecard project, conducts case studies on high-performing health care organizations, and is a contributing editor to the bimonthly newsletter Quality Matters. He has more than 20 years of experience working and consulting for government, corporate, academic, and philanthropic organizations in research, policy, and operational roles, and has au­hored or coauthored reports and peer-reviewed articles on a range of t health care–related topics. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. During 1996–1997, he was a public policy fellow at the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota. Kimberly Mueller, M.S., is a research assistant for Issues Research, Inc., in Durango, Colorado. She earned an M.S. in social administration from the Mandel School of Applied Social Sciences at Case Western Reserve University and an M.S. in public health from the University of Utah. A licensed clinical social worker, she has over 10 years’ experience in end-of-life and tertiary health care settings. She was most recently a project coordinator for the Association for Utah Community Health, where she supported the implementation of chronic care and quality improvement models in community-based primary care clinics. Jennifer Wrenn has 12 years of experience as a professional grant and technical writer and consultant in the fields of medicine, teaching, youth and family services, and immigrant services, with clients in Washington State and Colorado. Her work in the medical field has included writing case studies on high-performing health care organizations, securing funding for local health care access projects such as a Promotora (lay health worker) program and clinic serving immigrant and low-income clients, and working locally with the Citizens Health Advisory Council to research and implement an accessible and affordable community-based integrated health system. She previously worked as a physician assistant, focusing on care for the underserved and women’s health. Ms. Wrenn holds a B.S. in zoology from Colorado State University (Phi Beta Kappa) and a B.S. in medicine (physician assistant program) from the University of Iowa School of Medicine. K aiser P ermanente : B ridging the Q uality D ivide 27 A cknowledgments The authors gratefully acknowledge the following individuals who kindly provided information for the case study: George Halvorson, chairman and chief executive officer of Kaiser Foundation Health Plan and Hospitals; Donald Dyson, M.D., Sharon Levine, M.D., Bernadette Loftus, M.D., and Philip Madvig, M.D., associate executive directors of The Permanente Medical Group (Northern California region); Warren Taylor, M.D., medi- cal director for chronic condition management in the Northern California region; Kristin Snyder, Ph.D., vice president for quality and public affairs in the Colorado region; Richard Dell, M.D., Department of Orthopedics, Kaiser Permanente Bellflower Medical Center; Catherine Chen, manager of clinical systems planning and con- sulting; and Valerie Sue, Web analytics consultant in the Internet Services Group. We are grateful to the staff at the Kaiser Permanente San Francisco Medical Center who conducted a site visit for the Commonwealth Fund Commission on a High Performance Health System: Helen Archer-Duste, R.N., M.S., C.H.C., assistant admin- istrator; Christine Robisch, senior vice president and area manager; William Strull, M.D., assistant physician-in- chief; John Rego, M.D., chief of radiology; Christina Shih, M.D., assistant physician-in-chief; Anne-Tang, M.D., chief of the Bilingual Chinese Module; and Gina Gregory-Burns, M.D, chief of diversity. (Job titles may have changed since the time of the visit.) Robert Crane, senior adviser to Kaiser Permanente, kindly reviewed and commented on an earlier draft of the report. We also thank members of the Commission on a High Performance Health System, whose observations at the site visit informed the case study, and the staff at The Commonwealth Fund for advice on and assistance with case study preparation. Editorial support was provided by Joris Stuyck. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.