If the 1970s and 1980s brought a quality of care frenzy, circumstances in the 1990s conspired to create a veritable quality tsunami. Health care leaders reacted dramatically to a 1989 paper by industrial quality guru Donald Berwick and began to second guess health care reformers in Washington. Realizing their survival was at stake due to market pressures and government and employer demands for quality data, physicians and other health plan leaders dove head first into the quality quagmire.
Berwick’s message was revolutionary. His call to action was to take away the punitive side of quality review and bring all medical disciplines into a discussion of how to improve care processes and thus ensure better quality. Berwick’s influence was to abolish “The Theory of Bad Apples” in quality assurance and replace it with “The Theory of Continuous Improvement.”
Berwick, a physician in the Harvard Community Health Plan, had gotten his inspiration from Japanese industrial quality experts. Their carefully defined philosophy called “kaizen” led Japan to high quality factory production success. “An epigram captures this (Japanese) spirit: ‘Every defect is a treasure.’ In the discovery of imperfection lies the chance for processes to improve,” Berwick wrote in the New England Journal of Medicine Jan. 5, 1989 edition.
He adds: “Quality can be improved much more when people are assumed to be trying hard already, and are not accused of sloth. Fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to disaffection, distortion of information, and the loss of the chance to learn.”
Physicians rely on a support system to carry out high quality health care, Berwick noted. “Flawless care requires not just sound decisions but also sound supports for those decisions . . . In hospitals, physicians both rely on and help shape almost every process pertaining to patients’ experiences, from support services, such as dietary and housekeeping, to clinical care services, such as laboratories and nursing. Few (processes) can improve without the help of the medical staff.”
Berwick urged significant investment in assessing and improving quality of care. “In other industries, quality improvement has yielded high dividends in cost reductions that may occur in health care as well. . . The most important investments of all are in education and study, to understand the complex production processes used in health care; we must understand them before we can improve them.”
With Berwick’s message ringing in their ears, Kaiser Permanente leaders jumped into high gear. In September of 1990, the Kaiser Permanente Committee embraced Berwick’s bold new approach, which had been dubbed “TQM,” for Total Quality Management. At the same time, the Joint Commission on Accreditation of Hospitals also adopted TQM principles in its reviews.
In 1991, Jim Vohs, chairman of the board, and David Lawrence, MD, vice chairman and CEO, launched the Quality Agenda, an ambitious, all encompassing plan of attack to improve quality across all KP regions, involving all levels of the organization.
The 1991 Annual Report, titled the Quest for Quality, was devoted to chronicling the TQM phenomenon and explaining its genesis and hope for the future. The report acknowledged the work done previously by pioneers Sam Sapin, MD, and Leonard Rubin, MD, but declared the need to step it up:
“The role of quality assurance historically has been to identify problems within the system,” explained Susan Leary, director of quality assurance in the Program Office. “But with TQM,” she says, “we’re given new empowerment to go out and get involved in the planning process and to make system-wide changes once those problems are identified.”
A 53-page binder produced at the launch of the Quality Agenda defined the campaign as “A Roadmap for the Future.” The guide was to speed up KP quality improvement efforts and to intensify efforts to share good ideas and innovations across the regions.
The campaign emphasized the need to get all employees to understand and take part in quality initiatives. The roadmap outlined 5 specific tasks:
In 1992, the first annual interregional conference on Total Quality Management featured workshops conducted by Don Berwick, MD; Brent James, MD, renowned quality improvement expert and statistician of Intermountain Healthcare in Utah; and David Eddy, MD, the man who invented the computer model that could compile a wide range of health data and simulate a realistic clinical situation.
Eddy was hired by the Southern California Permanente Medical Group in 1991 to use clinical research data to evaluate the benefits and harms of different clinical interventions. Eddy compiled actual patient outcomes and ascertained which treatment would likely bring the desired results.
“One treatment (for lower back pain) might have a 30 percent chance of returning a patient to work, while another has only a 10 percent chance,” Eddy said. “But the first treatment might have greater risks. How do we decide if the greatest benefits of the first treatment are worth the risk? To determine this, we’d like to ask patients what they prefer. They’re the ones who will live or die by these decisions.”
From his research, Eddy set up a system to develop clinical guidelines or best practices to help physicians with decision making. “It’s simply unrealistic to think individuals can synthesize in their heads scores of pieces of evidence, accurately estimate the outcomes of different options, and judge the desirability of those outcomes for patients,” Eddy wrote in a 1990 article for the Journal of the American Medical Association.
In 1993, Lawrence published the Quality Agenda in Action, a report on quality initiatives across the program. Highlights included KP’s work with HMO groups and six large employers to develop the HEDIS (Health Employer Data and Information Set) quality measures and specific data collection methodologies for various treatments and preventive screenings.
The update also called out the Northern California Permanente Medical Group for its own launch of a program to establish best practices, vetted through research, and to implement and evaluate them. The Interregional Nursing Task Force brought together nurses from all regions to set up a system of best nursing practices.
A five-year study conducted by Southern California concluded that normal childbirth after a Caesarean section was possible and safe; while another study of 2.5 million patients in Northern California showed that screening for rectum and distal colon cancer with sigmoidoscopy decreased the rate of death from these conditions by 60-75%. In all, more than 350 TQM projects had been launched across KP’s 12 regions in the 4 years prior to the publication of Lawrence’s report.