What is quality health care and why it matters

How Permanente Medicine’s physician-led approach achieves medical excellence

Five factors influencing quality of care: 1) physician-leadership. 2) Connected health IT. 3) Evidence-based medical care and research. 4). A focus preventive care. 5) Culturally responsive care delivery.
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According to the National Academy of Medicine, quality health care is care that is safe, effective, patient-centered, timely, efficient, and equitable. The World Health Organization also includes “integration” — meaning care and services that are coordinated across providers throughout prevention, treatment, and maintenance — as a critical characteristic of quality care.

The ability of physician groups and health care systems to deliver on these elements goes a long way in determining the likelihood of positive outcomes and satisfactory care experiences for patients.

Defining barriers to quality

Unfortunately, health care in the United States typically operates in a way that hampers clinical excellence and often removes incentives to deliver high-quality care.

To start, there is a general lack of integration in health care services. Physicians, specialists, and hospitals are typically disconnected from each other and don’t routinely exchange patient health information and data. This leads to gaps in care, including missed health screenings, preventable medical errors, unnecessary or duplicative tests and services, and higher costs. It also makes preventing, discovering, treating, and managing complex health conditions — such as diabetes, heart disease, and cancer — more difficult.

The U.S. lags behind peer countries across a variety of quality of care, health outcomes, patient safety, and access measures

The Peterson Center on Healthcare and Kaiser Family Foundation

The traditional payment model in the United States — known as “fee for service” — further exacerbates lower-quality care. In the fee-for-service model, health insurers pay clinicians and hospitals for each service provided. This creates an incentive that encourages providers to perform as many tests and services as possible.

In contrast with fee-for-service, the value-based care model measures and pays providers against a budget for the care of a population. This model encourages prioritizing care that is tied to quality outcomes and allows for care to be delivered in lower-cost settings, including the home. In this model, effectiveness of care, cost-efficiency, safety, and the overall health of patients are the success metrics. Since the 2000s, value-based care has been an industry goal because it strives to improve overall quality of care.

Example of quality health care: Permanente Medicine

Kaiser Permanente’s physician-led integrated care model is recognized for its high quality, cost efficiency, and superior outcomes. It starts with the way our model is structured: All 8 Permanente Medical Groups work together with under a value-based mutual agreement to provide care. When care, coverage, and medical facilities are under the same umbrella, the financial incentives that encourage offering higher volumes of services are removed. Physicians can focus on preventive care and quality outcomes, instead of providing discrete services that drive income.

In this integrated system, Permanente physicians are free to focus on practicing medicine and providing compassionate, patient-centered care. Connected by integrated electronic health records (among the largest and most advanced collections in the country), physicians and care teams have access to patient health information across specialties and locations, making it easier to coordinate care. And with real-time access to accurate patient health information — including screenings, lab and test results, prescriptions, allergies, and prior physician notes — doctors and other clinicians can deliver the right care in the right setting at the right time. This unique approach to care is what we call “Permanente Medicine,” with quality and medical excellence as the goals.

This interrelated model provides further opportunities for quality improvement. For example, Kaiser Permanente has developed processes in which our pharmacy departments work closely with teams of prescribing physicians to establish a formulary that is based on the latest evidence (individual physicians have the freedom to make exceptions when appropriate).

Similarly, Permanente physicians and other Kaiser Permanente professionals identifies medical products — such as devices, durable equipment, and implants — that produce desired care outcomes. This approach aligns thousands of physicians, who use the same equipment and develop shared expertise, which further allows for cost-efficiency by giving Kaiser Permanente the ability to negotiate for lower pricing.

How coordination improves quality

Providing access to patient health records and information to multidisciplinary teams of physicians and clinicians helps ensure continuity of treatment for better outcomes. This helps eliminate missed or overdue screenings and avoids the ordering of duplicate tests, creating a better care experience while controlling overall costs.

In our integrated model, care is coordinated every step of the way. For example, our patient-centered approach to cancer care focuses on prevention, screening, treatment, and research to drive continuous improvement. Cancer screening schedules are personalized based on age, family history, and other risk factors to improve early detection. Lifestyle changes that impact cancer development are supported in a variety of ways, including nutrition and weight-loss programs, as well as tobacco cessation. Genetic testing connects patients and their family members with genetic counselors and physicians for careful monitoring. Patients also have access to innovative treatments such as immunotherapy and clinical trials, when appropriate. All of this happens within the same care ecosystem instead of across disparate and disconnected specialists and locations.

In a large Kaiser Permanente study published in the American Journal of Managed Care in 2021, we found that patients cared for in our Southern California integrated care delivery system had better survival rates for 8 common cancers over a 5-year period than patients who were cared for in other private settings. The survival rates were even higher for Black and Hispanic patients — just one example of how coordinated care can help address racial and ethnic health disparities. In addition, an internal study published in 2022 found that, in the communities we serve, Kaiser Permanente members were 20% less likely to experience premature death due to cancer compared to others in the community.

Quality and safety enhanced by health information technology

Health information technology enhances quality by improving the ability of physicians and care-team members to share clinical information. Advanced electronic health records allow physicians to quickly update information — including patient health histories, test results, imaging, and prescriptions — and make it available to both clinicians and patients, making it easier to coordinate care, share best practices, and identify potential clinical gaps or errors.

Permanente physicians practice medicine in a collaborative environment that’s transparent and digitally connected. All care encounters, whether in-person or virtual, are directly recorded in each member’s electronic health record. Physicians and care teams have access to all medical data for every patient, creating opportunities for quality improvement.

For example, built-in safety and screening alerts notify clinicians about potentially dangerous medication interactions, allergies, and upcoming or overdue health checkups. The alerts prompt staff to schedule screenings and appointments immediately, increasing prevention and early detection. Physicians order prescriptions via patient electronic health records, which are connected to our formulary and pharmacies.

Learning organizations with access to vast population health data have unique capabilities to support delivery science, which, in turn, guide the evolution of evidence-based advances in clinical care.

Nancy Gin, MD, FACP, Chief Quality Officer, The Permanente Federation

Permanente physicians make use of other innovative technology tools to drive quality. When they’re not in the same physical location, doctors can consult with each other by phone, video, and secure text messaging. This is especially valuable when, for example, a primary care physician needs to quickly consult with a specialist — who has real-time access to the patient’s record — for additional expertise.

Quality driven by evidence-based research and best practices

Another hallmark of quality care is the use of evidence-based clinical practice guidelines and best practices to drive care decisions. Clinical practice guidelines are a collection of care recommendations for specific conditions, and may include detection, diagnosis, and treatment.
At Kaiser Permanente, guidelines are developed under the National Guidelines Program. Permanente physicians and other clinical experts rigorously review and synthesize available medical evidence, turning it into expert panel recommendations that inform and guide clinical decision-making. To ensure they stay current, guidelines are routinely reviewed and updated at least every 2 years, or sooner if new evidence emerges.

Each year, the program convenes guideline directors from across the organization to evaluate and select priority topics to be included in Kaiser Permanente’s guidelines. Selection criteria may include but are not limited to:

  • Unwarranted variation in clinical or operational practice
  • Availability of multiple treatment options
  • Evolving evidence
  • High prevalence of condition or risk factors
  • High cost or resource use

Guideline teams are then assembled to develop the clinical recommendations. They include a core multidisciplinary group of physicians representing the medical specialties most affected by the clinical guideline topic, as well as pharmacists, health educators, and other medical professionals.

Guidelines are disseminated throughout Kaiser Permanente and made available to all Permanente physicians via our Clinical Library intranet site. This quick and convenient access to the guidelines enhances timeliness, efficiency, and effectiveness, all of which serve to improve overall quality of care.

Emphasizing prevention to drive quality for patients

Focusing on prevention reduces health risks, improves early detection for diseases, and increases overall quality of care. Unfortunately, many people in the United States don’t get the preventive care they need. Reasons include barriers to access, high cost, or simply not knowing when they’re due for scheduled screenings and checkups.

Our commitment to preventive care, a coordinated care approach, and electronic health records make proactive outreach to patients easier. Electronic alerts prompt physicians and other team members to schedule patients for preventive screenings, immunizations, and checkups. Convenient at-home tests for human papillomavirus (HPV) and mail-in fecal immunochemical tests (FIT) for colorectal cancer support early detection. And telehealth visits — including phone, video, and chat — for routine and preventive care can help reduce barriers for those with transportation or mobility issues.

Our efforts at prioritizing prevention have earned consistently high marks from the NCQA Quality Compass® HEDIS ratings for quality measures, including cervical, breast, and colorectal screenings; vaccinations; pre- and post-natal care; as well as controlling asthma, high blood pressure, and diabetes.

How health equity and culturally responsive care support quality

Providing culturally responsive care (also called culturally competent care) is an essential element in reducing health disparities and achieving equitable health outcomes. It’s a vital part of the patient-centered care approach and requires consideration of language preferences as well as social determinants of health (access to education, food, housing, jobs), cultural beliefs, attitudes, and behaviors when treating patients.

Culturally responsive care deliveryAcross the organization, physicians and care team members strive to deliver culturally responsive care to all patients. Interpreter services and member communications are provided in various languages. Culturally responsive care clinics serving specific populations such as Latino, Chinese, Black, Armenian, Vietnamese, and LGBTQ patients are offered at several of our medical facilities. Permanente physicians have access to language skills courses and certifications, as well as educational programs and trainings designed to reduce implicit bias and promote inclusion in care delivery.

Expanding access to underserved communities also makes it easier and more convenient for at-risk populations to get the care they need. Research from Kaiser Permanente in Southern California found that patients with low incomes had a 313.5% increase in virtual visits during the COVID-19 pandemic, while Latinos showed a nearly 300% increase in virtual visits across all income levels. And in Northern California, a proactive colorectal cancer outreach program eliminated screening disparities between Black and white Kaiser Permanente members.

Examples of quality in specialty care

Specialty care visits account for more than half of outpatient visits in the United States. Specialist visits for older adults — who typically use more health care services than younger people as a percentage of the population — have steadily increased annually, from 68.9% in 2000 to 76.1% in 2019. In a typical health care system, the risk of missed appointments, avoidable errors, duplicative testing, poor outcomes, high costs, and poor care experiences increases as referrals spread patient care among multiple and disconnected specialists.

Again, Kaiser Permanente’s integrated model goes far to solve issues created by the fragmentation of care. One example is our innovative blended perinatal program, piloted in California and Oregon, which shows how collaboration between primary care physicians, ob-gyn specialists, nurses, midwives, counselors, and other care team members creates a better care experience. This program for low-risk patients features an intentionally sequenced set of in-person appointments and virtual visits, remote-monitoring tools that log blood pressure and weight readings in the patient’s health record, and a Doppler device to check fetal heart tones. Developed in close partnership with Permanente physicians and operational partners, the program provides mothers the care they need, where they need it, and how they want it, in a way that would be difficult to do in the typical fragmented care environment.

Quality care that meets the moment

Working within an integrated care delivery model and sharing the latest best practices and evidence-based health information empowers physicians to make the best decisions for patients and ensures the highest quality care. This approach is not only the future of health care, it describes how Permanente physicians practice medicine today. It’s a key driver of how we’re able to consistently deliver expert, highly rated care everywhere we serve — care that’s safe, effective, patient-centered, timely, efficient, and equitable.