Permanente Journal Research Articles

Innovation in Our Nation's Public Hospitals: Interview with Five CEOs and Medical Directors

What quality improvement strategies are the leaders of our nation's prominent public hospitals following at this critical time of American health care change? Even more burdened than community hospitals with care for the uninsured and immigrant populations and with scarcer resources, how can they prosper, let alone survive? At the Spring 2007 annual meeting of the National Association of Public Hospitals in Boston, we talked with five leaders (Table 1) and found surprising and hopeful answers, and offer this conversation so that we can learn from them and follow their lead. Table 1 The participants The Permanente Journal (TPJ): Please briefly introduce yourself, your position, and give a brief description of your hospital health system. Sandral Hullett, MD (SH): Cooper Green Mercy Hospital is a small community hospital in the medical center affiliated with the University of Alabama at Birmingham, so we are a teaching facility. About 70% of the patients are uninsured; the other 30% are Medicaid, Medicare, and third party. We are a service provider for a large number of disadvantaged people. Fifty percent of our funding is from an indigent county tax. We've been there since 1972 and have been primarily a source for acute care though we are changing our image through more community-based work. Gene Marie O'Connell, RN, MS (GO): San Francisco General Hospital (SFGH) is the only trauma center in the city, with a full array of services in the acute care hospital as well as primary care and specialties, and the only psychiatric emergency unit in the city with the most psychiatric and mental health services of any area hospital. We have a total of 550 beds. Through an affiliation with University of California, San Francisco, we provide a third of all the teaching for the university. Last year we saw over 100,000 unduplicated clients. John W Buford, III (JB): Truman Medical Center (TMC)—a 501-C3, nonprofit entity that was originally the city hospital—is a two-hospital system that includes a long-term care facility, as well as a major behavioral health offering, and we oversee the Jackson County Public Health Department. Alan D Aviles (AA): The New York City Health and Hospitals Corporation is the largest municipal health system in the country. We serve about 1.3 million New Yorkers every year, including about 400,000 uninsured. The system includes 11 acute care facilities and 4 long-term care facilities and more than 80 community-based primary care sites. We have 4500 acute care beds and another 3000 long-term care beds. We provide 5 million outpatient visits per year and 1 million emergency room visits per year. We also run a very large Medicaid-managed care plan with more than 275,000 enrollees.

HIV Today: What's Encouraging; What's Discouraging

Lee Jacobs, MD Winter 2008 - Volume 12 Number 1 This and the next few issues of The Permanente Journal will have several excerpts from presentations at the 2007 Fifth National Kaiser Permanente (KP) HIV/AIDS, STD, and Hepatitis Conference held in April i

On The Use of Rapid Diagnostic Test Kits for Malaria

Since I wrote in The Permanente Journal (TPJ) (Fall 2005) about post-tsunami malaria in Indonesia, there have been several requests from TPJ readers regarding access to and anticipated availability of rapid diagnostic test kits (RDTs) for malaria. It is with regret that I relate that there is no intent to market these in the United States. There are several reasons for this, some valid, some not. Worldwide, the use of RDTs is a vital part of the World Health Organization's program for malaria control, to preserve the use of newer, more expensive regimens for actual malaria cases. RDTs are certainly, at a minimum, grossly comparable to an experienced microscopist and confirmation by a reference laboratory can be readily arranged after a diagnosis is suspected. The Centers for Disease Control and Prevention (CDC) often opposes the use of these kits for diagnosis of malaria. In a conversation with the malaria officer on duty, my suggestion that they were of use was disparaged. Unfortunately, as is sometimes the case, an organization such as the CDC does not respond to the requirements of actually delivering care. When an organization has ready availability of world-class parasitologists, there is little need for RDTs. On the other hand, few of us practice in such an environment. Kain et al1 described an average delay of three days between the time of ordering a malaria smear and confirmation of the diagnosis in nonspecialist Canadian medical centers. In view of the rarity of malaria in this country, our best laboratory technicians are inexperienced in making this diagnosis and even experienced parasitologists can make errors in their reading of blood smears. Our average hospital laboratory is likely inferior in sensitivity to RDTs and probably in specificity as well, particularly if we consider only P falciparum, the only species that is rapidly fatal. One published small series2 from Bethesda Naval Hospital reviewed the diagnostic accuracy of these two modalities among Marines with febrile illness evacuated from Liberia. Ten of 32 cases were accurately identified by RDTs and the same ten by thick smear. One of 32 patients had a positive RDT and a thin smear that was originally read as negative, but confirmed subsequently to have been positive. In 2004, in the US there were only 1324 reported cases, 49% of these were P falciparum.3 This seems to be a strong argument that our local labs will not be able to enhance their expertise in this disease. This would be even more significant for smaller hospitals in areas with less foreign travel among their patients. Different RDTs have been studied in various studies in nonimmune returning travelers from malarious areas. The accuracy of various tests does vary, but later generation tests for P falciparum routinely demonstrate sensitivities greater than 90% (88–99%) and specificities that are 95–100%. The conclusion of the meta-analysis by Marx and colleagues4 is that “rapid testing will lead to the detection of most clinically relevant P falciparum cases, with considerably better accuracy than that expected from routine microscopy in nonspecialist settings.” The arguments against the test are: the accuracy is not perfect; it is heat sensitive and it does not monitor the level of parasitemia, nor confirm efficacy of treatment. I believe these are false arguments. RDTs are certainly, at a minimum, grossly comparable to an experienced microscopist and confirmation by a reference laboratory can be readily arranged after a diagnosis is suspected. Identifying and starting treatment is the most vital part of diagnosis. The monitoring progress, while vital, can be arranged once a diagnosis has been confirmed. The argument of heat sensitivity seems disingenuous in North America where laboratory reagents are controlled for quality and stored in nontropical conditions. This is an argument of questionable validity even in tropical areas. In summary, in the US we are stuck with less effective diagnostic capabilities for malaria, when compared to most Third World countries. This is not expected to change in the foreseeable future.

Ethnographic Studies in the Principles of Clinical Medicine

Ethnographic Studies in the Principles of Clinical Medicine

Quality through Sustainability and Transferability

Is an innovative practice that improves quality sustainable? Can it be transferred to other sites in a whole system of care for a large population? The future of American medicine depends on affirmative answers. This issue's four Original Articles answer these more difficult questions about quality innovation through successful demonstrations. A good idea is not enough, and as noted by Arthur Huberman, MD, who chaired the Transfer of Successful Practices Workgroup of the Kaiser Permanente (KP) Care Experience Council: “The complexity involved in transferring successful practices is often underestimated. It involves much more than knowledge of the technical aspects involved. In fact, cultural issues usually present the most significant challenges.”1 The organizational process that lifts the most successful of these practices into view and recognizes them includes the Vohs Award for Quality and the Lawrence Patient Safety Award. With this issue, The Permanente Journal has published 23 Vohs Award projects over a seven-year period, and five Lawrence Award projects over three years, representing many KP regions and most major medical specialties.

The James A Vohs Award for Quality—The Eighth Annual Permanente Journal Special Issue

The James A Vohs Award for Quality—The Eighth Annual <i>Permanente Journal</i> Special Issue

Disaster Responses: Is the US Really Prepared?

The people of Kaiser Permanente (KP) continue to respond to the health care needs of survivors of major disasters. In this issue of The Permanente Journal (TPJ) (see page 59), we remember Katrina one year later by taking a glimpse at the experiences of KP responders as they cared for the evacuees in Houston and New Orleans.

The Southern California Perinatal Patient Safety Project

The Northern California Perinatal Patient Safety Project (PPSP) won the Lawrence Patient Safety New Project Award in 2004 (See “The Perinatal Patient Safety Project: New Can Be Great!” in The Permanente Journal 2005 Winter;9(1):25–7 and “Perinatal Patient Safety Project” in The Permanente Journal 2005 Spring;9(2):28–33). With the purpose to create high-reliability perinatal units through the use of human factors, techniques and systems improvements, the project borrowed from the United States Navy, NASA, and similar organizations that operate highly complex systems with few errors over long periods of time. Using the precepts of the “Four As of Adoption” (see “Practical Steps for Practice Transfer” in The Permanente Journal 2005 Fall;9(4):50–1), Southern California began implementation of PPSP in November 2003 at the Riverside Medical Center by administering the Safety Attitude Questionnaire (SAQ) to their Perinatal staff and physicians and initiated their PPSP Steering Committee to begin the planning process. The other nine Medical Centers began cyclical implementation in 2004. The purpose of the Southern California PPSP was to: decrease human error and identify patient care systems in need of improvement; create a safe culture; develop a high-reliability perinatal unit; and apply a “Just Culture” environment to create a safe environment for team members. The project included training in team briefings/communication, assertion, error detection, and situational awareness to include identification of “red flags.” A project tool kit was developed by the Southern California Regional PPSP project managers that described the core elements and was utilized by the medical centers during their start-up and throughout their planning meetings. This tool kit is now available from the National Risk Management Program Office (available at: http://kpnet.kp.org/qs/nrm/ PPSP3/toolkit.htm) or the Southern California Project Managers. This project tool kit has been so successful, it is being requested by medical centers outside of Kaiser Permanente (KP).

Why Research at KP?

Joseph Selby, MD Winter 2005 - Volume 9 Number 1 The impressive collection of Kaiser Permanente (KP)-generated research and implementation studies in women's health presented in this issue of The Permanente Journal suggests that many within our organ

The Women's Health Research Institute; Mission Overview with Featured Research Projects

Clinicians should participate in research. This participation in research is essential for validating and promoting innovative, evidence-based practice, and for improving the quality of care we deliver to our members. The Women's Health Research Institute (WHRI)1 was created in March 2001 to help Kaiser Permanente (KP) physicians and nurse practitioners to conduct clinical research related to women's health. Historically at The Permanente Medical Group (TPMG), most clinicians who wanted to conduct research had to do so on their own time, without any training or administrative support. In addition, the projects selected by these clinician-researchers did not necessarily fit with the strategic goals of the medical group. Many opportunities for interfacility collaboration were not being realized. The WHRI effectively acts as a broker between clinician-researchers and sponsors and coordinates studies involving more than one KP site or studies with other academic centers. WHRI projects have been funded by federal and KP grants as well as by grants from pharmaceutical and biotechnology companies. Some WHRI projects are traditional, multicentered clinical trials; others are investigator-initiated research projects. The WHRI team provides strategic oversight to ensure that projects are consistent with KP's strategic, operational, and quality goals. We assist WHRI investigators with administrative and operational support and training when necessary. We also provide compliance and regulatory oversight for new investigators who may not be familiar with US Food and Drug Administration (FDA) requirements and internal KP requirements for clinical research. … participation in research is essential for validating and promoting innovative, evidence-based practice, and for improving the quality of care we deliver to our members. To date, we have supported research by more than 20 KP clinicians in Northern California (Table 1) and have attracted more than $1.7 million in research funding. Figure 1 depicts the relationship between WHRI and other research bodies in Northern California. Figure 1 Chart shows relationships between the Women's Health Research Institute (WHRI) and other research institutions or sponsors in Northern California. Table 1 Current research projects supported or coordinated by WHRI This section on Research in this issue of The Permanente Journal features articles by three of our clinician investigators: Tracy Flanagan, MD; Maggie Che, MD; and Debbie Postlethwaite, NP.

The Permanente Journal Cosponsorship of the Evidence-Based Medicine Symposium, December 3 &amp; 4, 2004

Tom Janisse, MD Spring 2005 - Volume 9 Number 2 The Permanente Journal (TPJ) was privileged to join the Kaiser Permanente (KP) Care Management Institute as cosponsor of the Evidence-Based Medicine (EBM) Symposium held in Costa Mesa, California in early D

Enclave services: an office with a purpose.

Enclave services: an office with a purpose.

The james a vohs award for quality-the seventh annual permanente journal special issue.

Preventive interventions have far greater potential to improve the public health than treatment of existing medical problems. Doing the right thing includes a mandate to exert our best efforts to implement preventive strategies for our individual patients and for the general population. This year's Vohs award winner and runner-up both represent disease prevention programs. The winner is: “Tobacco Dependence Program: A Multifaceted, Systems Approach to Reduce Tobacco Use in Kaiser Permanente Members in Northern California.” The runner-up is described in the article: “The Kaiser Permanente Northwest Cardiovascular Risk Factor Management (CVRFM) Program: A Model for All.” The CVRFM Program also won the America's Health Insurance Plans (AHIP) contest for best quality CV project, making it a national benchmark. We are proud to present both projects in The Permanente Journal. “Just do the right thing.” — Chinese proverb Among the lifestyle and medical modifications that reduce vascular disease risk smoking is the only one amenable to total, safe, unequivocal elimination. The Northern CA Tobacco Dependence Program involves: 1) screening to ascertain tobacco users, 2) education of health care providers and performance feedback including awards for best results, 3) increased classes, in-person and telephone counseling, and 4) increased financial coverage of these measures. Tobacco use prevalence in Northern CA KP members has dropped by 11% during this program. Multiple factors may be involved in this decline. However, it seems likely that a substantial proportion is due to this fine program. The CVRFM program is designed to identify high-risk subjects with one or more risk traits for coronary heart disease, contact them, and institute favorable changes. In the initial “outreach” program to 8000 eligible members, 97% consented to participate. In the first 12 months, beneficial results among patients with multiple risk factors for atherothrombotic vascular disease were substantial. Similar benefits in terms of fewer later adverse events should follow. This type of effort has evident generalizability, similar programs have sprung up in other regions and cross-fertilization of ideas seems inevitable. The James A Vohs Award for Quality was established when Mr Vohs, a champion of innovation and improvement, retired from 17 years as President, CEO, and Chairman of the Boards of Kaiser Foundation Health Plan, Inc, and Kaiser Foundation Hospitals. The intent was to recognize and honor projects that advance the quality of care, showcase innovative techniques, produce transferable knowledge, and underscore the value of multidisciplinary teamwork. Annually, each KP Division may nominate one or two projects. The award is presented for the project judged to best represent an effort to improve quality through documented institutionalized changes in direct patient care. The selection criteria include demonstration of measurable improvement in care and potential for transfer to other locations. While the process for nomination has some local variation, each Division has contact liaisons easily located through the Regional quality representative. Nominations need approval by the Division President and Medical Director and applications are due September 1st each year. The Vohs Award Selection Committee announces its selection at the December Board of Directors meeting and the recognition ceremony takes place at the March Board of Directors' meeting. The Awardees receive no monetary gift but there is much recognition and publicity. The winning Division receives an engraved award, and project team members receive awards. Winners and runners-up are invited to present their projects at a reception hosted by the Boards of Directors, Division Presidents, and other Program Officers. The “real” award, of course, is the knowledge of having done good work that made a real difference in people's lives. The possibilities for projects are limited only by the imaginations of our health professionals. Undoubtedly many qualifying programs have not been submitted. Part of our purpose in publishing these projects is the hope that they will serve as models to motivate others to present projects for consideration. The process is an opportunity to share with 11,000 KP physicians and the general health care community your ideas about improving care of illness and providing health information.

Roman Windows

Spring 2005 - Volume 9 Number 2 "Roman Windows" photograph By Tom Janisse, MD Dr Janisse is the Editor-in-Chief of The Permanente Journal. This photograph was taken in Umbria, Italy.

Stories Tell Us What We Need To Know: Perspective for Ethical Dilemmas-The Story Study.

(Portions of the text, and the first story study, are excerpted from Ethics Rounds 2003–04 Winter;13(14), and from The Permanente Journal 2003 Winter;6(1) and The Permanente Journal 2004 Winter;8(1).

Touching the Customer by Understanding Employees: Preliminary Linkage Research Findings from Four Regions of Kaiser Permanente

This study used data from four Kaiser Permanente Regions to examine the relations between employee opinions, customer opinions, and business performance. The preliminary questions we asked regarded whether facilities in which employees expressed more favorable work attitudes were also facilities which 1) had more satisfied members; 2) had better financial performance; 3) had more members; and 4) served more patients. Generally speaking, employee opinions were strongly and positively related to customer (member) opinions. More specifically: • Customer satisfaction is most related to employee opinions of doctors, organizational flexibility, and training for customer service. • Employee perceptions of doctors are very strongly related to customer perceptions. • Customer ability to see their provider is the customer’s window into the operational effectiveness of that location. • Service training is also strongly related to customer service perceptions in general, even the perceptions specifically about the physicians. Unfortunately, clear links were not found between either employee or customer opinions and business performance (eg, financial measures). We continue to examine these relationships, and others, in an attempt to further our understanding of these complex issues. We hope to report these results in future issues of The Permanente Journal. Note: These early findings represent a first step toward understanding the relationships between what employees think and how Kaiser Permanente performs. Future submissions to The Permanente Journal will report additional findings, including specific examination of the relation between employee opinions and the STAR Care Index as well as a companion article that provides the practical implications of this work, written by senior Human Resources executives within Kaiser Permanente.