In 1994, drawing talent from the Permanente Medical Groups (PMGs) and Kaiser Foundation Health Plan/Hospitals (KFHP/H), a unique quality oversight and improvement program--the Medical Directors' Quality Review (MDQR)--was developed. Now in its fourth year of implementation, the MDQR has not only contributed to the outstanding record we have established with the National Committee for Quality Assurance (NCQA), but has changed the way we structure and implement quality assurance and improvement across KP. The MDQR combines a quality improvement orientation, a standards-driven survey process, audits of records, and peer consultation to implement national quality assurance standards that are among the highest in the nation.

The MDQR was first implemented under the direction of the Medical Directors' Quality Committee (MDQC) in 1995. As an agent of the MDQC and the KFHP/H Boards' Quality and Health Improvement Committee (QHIC), the MDQR is different from traditional corporate and board of directors' oversight processes in three important ways:

Unlike many quality oversight activities, a high degree of candor and constructive feedback predominates as physicians, nurses, and other quality assurance professionals discuss their findings and provide peer consultation onsite. As a peer review process, the MDQR is conducted in accordance with peer review statutes to assure confidentiality and legal protection for findings. The findings are reviewed by the MDQC and are used to inform the QHIC, which then provides an independent assessment of the survey results.

History of Formal KP Quality Assurance Programs
Formal quality assurance activities, designed to "measure and minimize variations from what is considered desirable based on current knowledge,"¹ emerged as early as the 1960s within The Permanente Medical Group (TPMG) of Northern California with the advent of the Comprehensive Quality Assurance System (CQAS).² Similarly, formal quality assurance programs arose in the Southern California, Northwest (Portland), and other KP Regions. As these programs grew in sophistication, they played an important role within KP and contributed to the national evolution of quality assurance. For many at KP, however, the primary focus became compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) inpatient standards, as was the case in much of the health care community.

In the late 1980s, consumers, regulators, and purchasers began to question the health care industry's ability to provide effective oversight through its traditional internal mechanisms. Consequently, various health care "watchdog" groups emerged, regulators began to toughen their oversight, and the purchasersponsored NCQA rose to prominence.^a

History of the KFHP/H Boards' Quality and Health Improvement Committee (QHIC)
In 1983, the KFHP/H Boards formed a quality subcommittee--the Boards' Committee on Quality of Care (BCQC)^b--in response to heightened awareness by members of the KFHP/H Boards of their fiduciary responsibilities,³ especially as they related to quality.^c

In 1983, intending to vigorously exercise these duties and responsibilities in the best interests of those served by the Program, the BCQC began to conduct onsite quality review visits periodically (ie, every 1218 months) to the KP Regions (nine in 1983, expanded to 12 by 1986). The threefold objective of the quality review visits was to evaluate KP Regions' quality structure and processes, to ensure that leadership was performing its role, and to exercise the Boards' responsibility to assure patient safety.

The Boards' annual reviews continued through the early 1990s and led to continued improvement of the KP Regions' quality processes and infrastructure. However, these efforts neither inspired the rapid improvement necessary to meet growing expectations (of consumers and others) nor led to the improvement needed for compliance with NCQA requirements or Health Plan Employer Data and Information Set (HEDIS) performance measures.

Mutual Accountability, Permanente Medicine, and the Medical Directors' Quality Committee (MDQC)
In 1994, David Lawrence, MD, Chief Executive Officer of KFHP/H, asked the PMG Medical Directors to propose a new approach to the KP Program's quality review process. In particular, KP Program leaders wanted a process that would foster collaboration between KFHP/H and PMG quality leaders, provide the Boards with the information they needed to continue their oversight responsibilities, and improve quality performance across the KP Program.

In a parallel, related conversation--one that eventually led to formation of The Permanente Federation (TPF)--the value and advisability of autonomy for each PMG was questioned by PMG leaders. Medical Groups could no longer operate in relative isolation within their geographic markets. Any serious breach of quality or performance became national news and touched all PMGs. At issue was the vision of a much closer relationship among the Medical Groups, characterized by performance requirements and "mutual accountability."

Performance requirements--Permanente Medicine^d--became seen as a necessary and desirable prerequisite to "flying the Permanente flag." However, if the PMGs were to be mutually accountable for performance, an evaluative process would be needed to measure performance and to establish accountability.

Against this backdrop, the MDQC was formed and given its mission to develop and implement "a quality review structure and process that in its actualization will help ensure and improve the quality of care and service to Health Plan members and other customers." Although not readily apparent from its name, the MDQC was composed of KFHP/H as well as PMG representatives.^e

Eight standards were developed by the MDQC in late 1994, and four of these were implemented in 1995 by reviewers for the new MDQR quality review process. The name MDQR was selected to emphasize the Medical Directors' commitment to national quality standards for all PMGs. This commitment represented a substantial change in policy and culture from the individual group autonomy practiced since the 1940s.

Standards were crafted as "stretch goals" that might not be universally achievable for some time but that established the vision for quality structure, process, and accountability. The development and implementation process harnessed the energy and commitment of the KP quality assurance community as nothing else had done; the standards were challenging and intended to support superior performance. Accountability was expected, but it was accountability based on a learning model instead of an enforcement model.

Since the inception of the MDQR, more than 100 KP quality assurance professionals and physicians have been trained as MDQR surveyors. The training is a rigorous process that extends over two days. Surveyors volunteer their time, energy, and expertise to be trained and to participate in one or two surveys per year. Almost without exception, they report the process to be personally and professionally rewarding, both for what they can offer colleagues and for what they take away from each survey.

Implementation of the Medical Directors' Quality Review
Joint responsibility for directing the new quality reviews was assigned to Sharon Conrow, Vice President for Quality at KFHP/H; and Rob Formanek, MD, of The Permanente Federation (TPF).^f In 1995, the two worked closely together with Kathy Antis of the Department of Care and Service Quality, Diane Hedler of TPF, and others in the MDQR Work Group^g to design and prepare the quality review process for implementation.

The MDQC originally developed eight standards:

Initial quality reviews were conducted in 1995 for each of the 12 KP Regions.^h In 1996, 14 quality reviews were conducted; one each for the 12 KP Regions reviewed in 1995, one for Community Health Plan (CHP) in the Northeast, and one for an additional nonKP health plan that was under consideration for merger or acquisition.

On the basis of the 1995 finding that peer review processes varied greatly across the KP Regions and within the PMGs, in 1996, a work group composed primarily of Permanente physician leaders crafted a ninth standard: the Practitioner Performance Review and Oversight (PPRO) Standard. Like all MDQC standards, this standard aimed to represent the ideal. It was also intended to "raise the bar" for quality assurance across the PMGs and all parts of the KP Program.

Similarly, other expert work groups were formed to improve credentialing practices and to improve the management of quality in affiliated (contract) relationships such as physician networks. An audit process using sampling techniques was designed and implemented in cooperation with the KFHP/H Internal Audit Department to provide quantitative data about the completeness of credentials files. The information obtained through the 1997 audit process identified several areas of underperformance. These areas have now been improved to acceptable levels, and the degree of improvement has been quantified by additional audits in 1998.

In 1996, Terri Kielhorn, JD (of the KFHP/H Department of Care and Service Quality) and Andy Wiesenthal, MD (of the Colorado Permanente Medical Group) led KP Program risk management experts in an extensive effort to achieve agreement on data specifications and processes. As obvious as it may seem, such agreement has in the past been elusive. The work was codified in the revised Risk Management Standard. Because of this standard, we are now able in 1998 to compare performance data for risk management activities across the entire KP Program. Long overdue, this ability to compare is a historical first for risk management. Starting in 1997, a work group developed KP guidelines for proctoring and privileging, and these will be assessed in 1999 as part of the QCHP Standard.

MDQR Redesign
True to the principles of continuous quality improvement, the members of the MDQCⁱ are themselves currently in the midst of a determined effort to reinvent and streamline the MDQC functions and the MDQR process. Changes for 1999 include:

Summary
The MDQR is designed to improve and bring consistency to quality management practices, to our collective performance, and ultimately to the quality of care and service provided to our members. The MDQR draws its strength and richness from participation of the many quality assurance professionals and physicians who generously volunteer their time, energy, and expertise. Obviously, the success of the MDQR directly involves reviewers and reviewees. Not so obviously, but of even greater importance, the MDQR can only achieve its mission by the work of the many committed clinicians and other health care professionals within the KP system--those who directly care for and serve our members.

Nothing quite like the MDQR exists in any other managed care program. It represents our best effort to establish a model for quality oversight while embedding within it the capability to stimulate learning and set the stage for continuous improvement.

For a list of MDQR reviewers, click here.

^a With participation from KP quality assurance leaders, the National Committee for Quality Assurance (NCQA) was guided in its creation in 1980 by the Group Health Association of America (GHAA) and the American Association of Foundations for Medical Care (AAFMC). This effort was in response to a request by the federal Office of HMOs. The original Board of NCQA, in addition to representatives from group practice prepaid plans and independent prepaid practice associations, had consumer and business representatives. Over time, NCQA has become the primary national accreditation agency for managed care organizations.

^b The KFHP/H Boards' quality subcommittee was renamed the Boards' Quality Committee (BQC) in 1995 and in 1997 was given its current name: the Boards' Quality and Health Improvement Committee (QHIC).

^c These responsibilities include provision of a safe physical environment as well as proper equipment and resources for patient care; internal policies and procedures that protect patients and members; proper selection and retention of KFHP/H staff; and reasonable measures taken to guarantee the administration of sound patient care.

^d These performance requirements were initially spoken of as Permanente Practice and more recently as Permanente Medicine.

^e Members of the MDQC in 1994 included Sharon Conrow, DrPH, KFHP/H VP Quality; F. Jay Crosson, MD, TPMG; David Lawrence, MD, KFHP/H CEO; Ian Leverton, MD, PMGIS; Don Neilsen, MD, PMGIS; Larry Oates, MD, MAPMG; Ron Potts, MD, OPMG; Richard Rodriguez, MD, TSPMG; Al Weiland, MD, NWP; Andy Wiesenthal, MD, CPMG; and Les Zendle, MD, SCPMG.

^f The Permanente Federation (TPF) did not exist in 1995. Its predecessor, the Permanente Medical Groups Interregional Services (PMGIS), was renamed Permanente Interregional Consultants (PIC) in 1996, and in 1997 PIC was replaced by TPF. The KFHP/H Department of Care and Service Quality is the current name for the former Department of Quality at KFHP/H.

^g Currently, members of the MDQR Work Group include Kathy Antis, RN, DCSQ; Tracey Cameron, MBA, TPF; Barbara Elenteny, RN, PhD, DCSQ; Rob Formanek MD, TPF; Sharron Garvisch RN, DCSQ; Diane Hedler, RN, TPF; Terri Kielhorn, JD, DCSQ; and Jed Weissberg, MD, TPF.

^h The 1995 Ohio MDQR was conducted in January 1996; the 1996 Ohio MDQR was conducted in August 1996.

ⁱ Current members of the MDQC include Kathy Antis, DCSQ (acting); Dick Barnaby, KP-California Division; Rob Formanek, MD, TPF; Bill Gillespie, MD, DCSQ; Diane Hedler, RN, MS, TPF; Phil Madvig, MD, TPMG; Larry Oates, MD, MAPMG; Bruce Perry, MD, TSPMG; Patricia Siegel, RN, MS, KP-California Division; Jed Weissberg, MD, TPF (chair), TSPMG; Andy Wiesenthal, MD, CPMG; and Les Zendle, MD, SCPMG.