Kaiser Permanente patients might feel more satisfied with the better and safer care they're reportedly receiving through a partnership with the Institute for Healthcare Improvement, but Kaiser's 13,000 physicians and other caregivers could get a little nervous with patient-safety pioneer Donald Berwick analyzing their every move.
A $10 million collaboration between Oakland, Calif.-based Kaiser -- which operates more than 400 medical facilities in nine states and the District of Columbia -- and Cambridge, Mass.-based IHI, which Berwick heads, seeks to leverage the resources and 8.5 million-member base of the nation's largest not-for-profit integrated health system to improve patient safety and satisfaction across the land. Participating providers will be put under a microscope, which may raise their performance anxiety while leading others to question if true healthcare transformation can only occur if big dollars are attached.
"We're absolutely focused on improving front-line" care, says Lisa Schilling, a nurse and a Kaiser patient-safety practice leader, explaining that the general idea behind the initiative is process improvement. "Let's identify what's not working. Let's measure. Let's test," she says.
Doug Bonacum, Kaiser's vice president of safety management, adds that the intent is to share any innovations that are developed as a result of the collaboration. "We, at Kaiser, basically refuse to compete on safety," he says.
One of the leaders of the collaboration, IHI Senior Vice President Rashad Massoud, says he is aware that his organization is a facilitator but not the driver of quality-improvement efforts at Kaiser.
"Kaiser Permanente has 145,000 employees, we're an 85-person organization," he says. "We're realistic about the proportion."
Launched in December 2004, Kaiser's collaboration includes scholarships -- funded through an $8 million endowment to the IHI -- for Kaiser employees and workers at other organizations that partner with Kaiser to attend IHI education and training programs over the next 15 years. Topics include clinical outcomes; patient safety and satisfaction; office and hospital redesign; and healthcare access and disparities.
There's also a $2 million contract for IHI to provide "strategic guidance" on patient safety, organizational metrics and management; assistance with innovation pilot tests that use IHI methodology; guidance in leveraging results to positively affect more patients; and help with organizational structure improvements such as staff training and skills development.
"Kaiser Permanente is excellent at everything somewhere," Bonacum says. "We want to be excellent everywhere, and we think we can do that with IHI's help."
Berwick, IHI's president and chief executive officer, echoed a similar sentiment during a Sept. 27 Kaiser Family Foundation symposium on healthcare improvement.Berwick mentioned how several hospitals working with IHI have gone months without a central-line infection and asked "If there, why not everywhere?"
Berwick, who was not available for comment on this story, was involved in hammering out the collaboration with Kaiser and is active in managing its progress, an IHI spokeswoman says.
Bonacum added that the collaborative effort was "brokered" in a large part by the longtime working relationship between Berwick and Louise Liang, a past chairwoman of the IHI's board of directors and Kaiser's senior vice president of quality and clinical systems support. In the early '80s, Berwick was vice president for quality-of-care measurement at the Harvard Community Health Plan while Liang served as associate medical director.
In addition to Kaiser, Massoud says IHI has similar but smaller-scale relationships with HHS, Allina Hospitals & Clinics, Minneapolis; national alliance Premier; Ascension Health, St. Louis; as well as partnerships in Sweden and the U.K.
"We partner with organizations that can leverage IHI's work to thousands of patients," Massoud says. "One of the things (Kaiser) brought to the table is that they have made the single-largest investment in electronic medical records outside of the military."
Considering that Kaiser is spending some $3.2 billion on its HealthConnect EMR system, Massoud says the goal is to squeeze every last benefit out of that massive expenditure and to answer the question of "How can we make this the best investment they've ever made in the area of improving quality of care?"
"We have an expensive IT system," he says. "You can show up in any part of the Kaiser Permanente system -- from Hawaii to Washington, D.C. -- and we will know you."
The key, however, is to make use of this resource beyond the random emergency department visit by a tourist visiting another state. Bonacum says Kaiser is working to automate IHI's "trigger tool" strategy that calls for some 20 random chart reviews a month to check if any unnoticed adverse events or patient harm may have occurred. The practice is now done manually at Kaiser, and Bonacum says the goal is to have it done electronically, which would be more efficient in terms of staff time.
Schilling adds that this is also important because programs can flag incidents that are considered adverse events by patients. For example, a patient may be nauseated for several days and this may not have been officially registered as an adverse event or patient harm, but that individual patient may think differently.
Massoud says he was particularly excited about a Kaiser project now being tested where physicians have a telephone consultation with patients whose chronic care they are managing. Both doctor and patient view the patient's medical record on a computer during the discussion.
"Imagine the difference in having a 15-minute phone conversation at home without the driving, waiting and driving back of a typical office visit," Massoud says. "We realize the future of medicine is in that type of interaction, and Kaiser Permanente is leading the way in that respect."
Early indications are that such a method for managing chronic conditions "increases patient satisfaction dramatically," Massoud says.
Observers agree and say they are glad Kaiser is pushing programs like this forward.
"We think it's the future as well, but the reason we haven't seen a lot of uptake is twofold," says Steven Waldren, director of the American Academy of Family Physician's Center for Health Information Technology. He explains that there are medical-legal issues attached to concerns that the introduction of new technology may introduce some new way of harming patients, but the driving issue is reimbursement. "I think the fact Kaiser Permanente is doing this will help the market understand that the benefits (of IT) outweigh the risks, and it will help with reimbursement issues as well," Waldren says.
The Kaiser strategy for physician adoption calls for pilot testing, collecting loads of data and then using IHI communication techniques to get providers onboard.
"If you want to change a practice, show evidence that it works," Schilling said, adding that nurses always remember incidents where they caused a patient harm, so they are receptive to evidence-based solutions that prevent such incidents from reoccurring. "They never forget. It haunts you."
Boosting patient satisfaction is a key goal and motivator for Kaiser's efforts. Another is to link the increased satisfaction with an awareness that it was Kaiser achieving those gains. A Kaiser spokeswoman noted that one objective of the collaboration was, in fact, elevating Kaiser's prominence as a national quality leader. This is consistent with one of the values Kaiser lists for HealthConnect: "KP brand image is enhanced with more patient-centered care and new service modalities."
Kaiser, however, isn't the only company conducting high-profile quality-improvement projects.
For example, Misys Healthcare Systems, a Raleigh, N.C.-based EMR provider, has launched the Center for Community Health Leadership, which it will use to donate and distribute up to $10 million worth of health IT software to help advance EMR adoption. The program calls for a community's healthcare leaders to set local milestones for adoption while engaging in a dialogue on the best IT practices and other issues concerning the advancement of a national interoperable healthcare system.
Chicago-based Aon Healthcare has launched its Return on Risk strategy, which Debra McBride, vice president with Aon Risk Services of Minnesota, says "perfectly mirrors" what Kaiser is doing.
The strategy involves establishing hundreds of small regional pilot projects exploring topics such as improving patient flow and removing emergency department bottlenecks and then fast-forwarding the innovations that work out into the community, says McBride, a nurse and an attorney.
She added that there are advantages to having big healthcare systems driving the improvement process.
"Data is the key to change," McBride says. "And having meaningful data requires pooling. That's why outside assistance has really spurred this movement."
While large organizations spending millions of dollars grab the lion's share of the industry's attention, smaller facilities implementing home-grown quality-improvement efforts are also doing their part to transform healthcare.
"We're certainly not a Kaiser by any means," says Cassy Horack, director of quality and safety at OSF St. Francis Medical Center in Peoria, Ill., a 593-bed facility and the largest in the six-hospital OSF system. "But change can be done, no matter how big or small you are. But you have to have the commitment from the top down. You have to have the culture."
Using the Six Sigma quality-improvement methodology developed by Motorola to produce nearly defect-free products and services, St. Francis launched its quality efforts in February 2001 with the simultaneous launch of 11 separate projects. "You have to have a methodology; we just happen to have Six Sigma," she says.
Though she credits the Six Sigma system for much of her hospital's success, Horack says the system doesn't follow it to the letter.
"They want you to quantify financial gains," she says. "We've taken a stand that -- for patient safety -- dollars don't matter when you can save a human life."
OSF St. Francis has worked with the IHI and has staff that has done work for the organization. For instance, John Whittington, the patient safety officer for the entire OSF Healthcare System is an IHI faculty member. But the system's initiatives-such as work on preventing ventilator-associated pneumonia and pressure ulcers -- often predate those launched by the IHI or mandated by the Joint Commission on Accreditation of Healthcare Organizations.
Its current ahead-of-the curve activities along those lines include initiatives on blood-sugar management, anti-coagulation management and deep-vein thrombosis prevention. "We're always dabbling in something," Horack says. "You can keep plugging away to do things that are not in the national spotlight."
Data measurement is a big part of the initiatives, and Horack says one of the keys is to select someone in each hospital department to be a "process owner" who is accountable for the indicators presented in the data. If the indicators on a department's scorecard fall below an acceptable rate, the process owner is required to develop an action plan to reverse the trend.
This constant measurement is referred to as "practicing in a fishbowl" in one Kaiser document, but Horack says such an approach is welcomed more often than not.
"From a managerial perspective, it's a huge relief because there's something you've been trying to improve, but haven't been able to," she says. "And now you know you'll get the resources to do it."
Not Big Brother
Schilling says Kaiser Permanente's collaboration with IHI isn't creating a sense of Big Brother.
"It's not about Don Berwick looking over your shoulder and creating a sense of anxiety," she says. "They're helping us rise to the challenge."
Massoud says that, rather than creating anxiety, staff observation for quality-improvement purposes often relieves anxiety for many providers who felt hindered by a lack of progress in quality, safety and patient-satisfaction improvement.
"They find a liberation and a means to accomplish why they got into healthcare in the first place," he says. "I see energy. I see people's eyes light up."
Catrina Sniffen, a nurse at Kaiser's Woodland Hills (Calif.) Medical Center, says staff generally finds value in such observation and tracking as long as it has a purpose and they're not just collecting data and tucking it away some place.
"For me, personally, I don't feel pressure because it's part of giving good nursing care," she says. "Some people need that extra push. ... But I think it's great that they do track and do studies. That way everyone is informed and, if you need extra help or training, it's there. I'd say a large percentage of the nurses like doing" studies.
Although patient satisfaction has been a big driver in quality-improvement efforts, Aon's McBride says staff satisfaction and retention is critical to any quality initiative.
"Empowerment of the staff will move this forward," she says. "Even a small turnover can wreak havoc."
The big problem occurs when training duties get added to a nurse's regular workload.
"It takes resources away from the bedside," McBride says. "People who feel overwhelmed start to call in sick. They think, 'I don't want to work with two new nurses today. Let someone else deal with it.' "What do you think? Write us with your comments at [email protected]. Please include your name, title and hometown.