Quality. Ask a hundred people to define it, and you’ll get a hundred answers. In the last decade we’ve collected more performance data and industry rankings than ever to sharpen that fuzzy definition. Members, health coalitions, purchasers, consumer advocates and the media all rate Group Health’s quality in different ways.

In 2010 we’ve earned some major quality endorsements that we can all be proud of:

• The National Committee for Quality Assurance (NCQA) just renewed Group Health’s ‘Excellent’ accreditation for HMO Commercial and Medicare plans. Evaluators gave us a 99 percent defect-free rate in their June 2010 site visit.
• U.S. News and World Report ranks Group Health in the top 4 percent of Medicare plans nationally, and in the top 26 percent of commercial plans.
• Group Health medical centers just garnered the most top marks out of 76 medical systems in the Puget Sound Health Alliance’s 2010 “Community Checkup,” released this month. Our medical centers have had the highest performance in each of the four reports since it started.
• J.D. Power and Associates ranked Group Health "Highest in Member Satisfaction among Commercial Health Plans in the Northwest" for 2010.
• The 2010 results from eValue8, a purchaser-led assessment of health plans, shows we were the highest-ranking plan in the region, for six of seven categories, including Pharmaceutical Management, Behavioral Health, Prevention and Chronic Disease Management. 

Building accountability
These results are great, and they give us a concrete way to talk about quality. Yet I think what really sets us apart is our unflinching transparency.

Most health organizations are required by regulatory agencies, or by purchasers, to report certain performance results. Yet Group Health is one of only 250 plans nationwide that opens its methods to scrutiny and provides all results—not just the good ones—to the National Committee for Quality Assurance (NCQA) Quality Compass.

The Quality Compass is a public database used by purchasers, brokers, consumers and others to make healthcare purchasing decisions. We build accountability with these decision-makers when we are up front about our strengths and weaknesses. We think our patients and purchasers deserve transparent information, and we believe that using it helps us get better.

Measuring ingredients vs. baking cakes
My only quibble with quality measurement is that traditional measures can be too narrow for an integrated system like ours. We’re measured in hundreds of different categories—the ingredients of care. But we’re baking cakes: doing multi-layered, interdisciplinary work that deepens the meaning of quality.

• We’re empowering patients to learn their options and decide whether certain surgeries and alternatives will work for their lifestyles.
• We’re tightly coordinating hospital care, discharges and changes in care settings, so people are less likely to take a turn for the worse and return to the emergency room.
• We’re building evidence-based best practices for radiology use, reducing unnecessary radiation exposure, especially in young people.

Then there are the nuanced ways our members define quality for themselves. For the busy professional, it’s a short pharmacy line with a credit card scanner at every window. An expectant mother gets a choice of midwives or obstetricians. Electronic medical records give an older adult freedom from carrying a dog-eared list of unpronounceable medicines in his wallet.

Every day, we have thousands of opportunities to measure up—to build patient confidence and trust in our work. The more subjective aspects of quality aren’t calculated point-by-point in scorecards and rankings. But I think they’re the icing on the cake.

Questions or comments? Respond to Open Mike

High-end imaging tools such as computed tomography (CT) and magnetic resonance imaging (MRI) are invaluable for diagnosing disease, trauma, or abnormalities in patients with symptoms of illness. But use of these tools—and their cost impact on the health care system— has increased dramatically in the last decade.

Nationally, Medicare spending on these services increased 17 percent per year between 2000 and 2006: from $3.6 billion to $7.6 billion. Group Health Research Institute studied the same trends, and in 2009 reported Group Health had doubled its MRI rates and tripled its CT scan rates over ten years. This increase in imaging has resulted in increased radiation exposure to our patients, but has not necessarily led to better outcomes.

How do we use high-end imaging to support quality care?
Group Health Radiology Service Line Chief Robert Karl, MD, believes we can flatten or reverse this trend in our Group Practice. An Enterprise-wide improvement initiative for high-end imaging is underway.

“Our goal is to use imaging where it’s most effective for each patient,” says Dr. Karl. “At the same time, we should be able to reduce patients’ radiation exposure by reducing unnecessary scans.” Central to the effort is a new set of decision support tools for providers in the Epic medical record system.

According to Dr. Karl, these tools allow providers to analyze and rank the usefulness of imaging studies they order. “This creates a knowledge base of best practices. It shows us where we are getting the best diagnostic results with image studies, and which are unnecessary, based on medical evidence.”

Group Health radiologists also use provider-to-provider messaging within Epic to consult with and support referring clinicians. And they’re available around-the-clock for phone consults related to ordering radiology services.

Balancing benefits and unintended consequences
Clinicians rely on imaging to speed the path from diagnosis to treatment. Consider a patient with signs of lymphoma. CT scans now replace exploratory surgery to find tumor evidence in her spleen. Treatment can begin sooner without a post-surgical healing period.

Yet outcome evidence shows that for some conditions, high-end imaging doesn’t yield any more information than a detailed clinical exam or watchful waiting. Even an abnormal finding may not be serious or life threatening, but over-using high-end imaging to investigate further does not necessarily help in the long run. Research indicates that at least one percent of all cancers can be attributed to medical radiation exposure.

The improvement team is paying particular attention to appropriate use of CT scans in children and adolescents, to moderate their lifetime radiation exposure. One chest scan can give 50 to 80 times the amount of radiation in a series of full-mouth dental X-rays.

Health care reform legislation is prompting state health policymakers to analyze costs and efficacy in high-end imaging too. Dr. Karl represents Group Health and the Washington Healthcare Forum to the state’s Advanced Imaging Management (AIM) Workgroup. He’s providing an expert view on the appropriate use of imaging, balancing patient care and effective imaging management.

Dr. Karl maintains that there will always be an art and a science to applying these tools, based on professional judgment and experience.

Questions or comments? Respond to Open Mike

The optometric residency program at Group Health Eye Care-Tacoma has been accredited by the Accreditation Council on Optometric Education (ACOE), the nation’s only accrediting body for professional optometric programs.

The Tacoma residency program passed ACOE evaluation criteria with flying colors on its initial attempt. “No other program has achieved accreditation on its first try, without follow-up recommendations,” says Terrence Clark, OD, who leads the Tacoma residency.

A team effort
Dr. Clark credits thorough preparation by Group Health’s Lynna Kim, OD and Carol Hsiao, OD, as well as Judy Tong, OD, residency coordinator and assistant professor at the Southern California College of Optometry. “The hard work and thorough documentation on the part of our current resident, Sara Rondeau, OD, played no small part in the success of the program as well,” he says.

Dr. Clark feels that accreditation makes a big difference to optometric residents. “For potential residents, it shows we’re a rigorous program, and it makes our current residents eligible for a wider variety of openings in practice and in teaching.”

Group Health Eye Care also has a Seattle residency program at its Northgate location. That site was ACOE accredited in 2008 under the leadership of Stuart Frank, OD. The Tacoma group acknowledges the Northgate program’s groundwork and guidance in preparing for a smooth accreditation process.

Optometry's role in primary care
Group Health optometrists provide comprehensive eye exams and prescriptions for eyeglasses and contact lenses, serving both Group Health members and the general public at 14 locations.
Group Health optometrists work closely with ophthalmologists and primary care providers

“Eye Care at Group Health is unique in its coordination of services, with optometrists and ophthalmologists working together, each at their highest level of training”, says Philip C. Paros, OD, Eye Care Service Line Chief. “This coordination of clinicians allows us to deliver comprehensive, quality care in prevention and management of eye disease to the patients we serve.

“I am grateful to Consultative Specialty Services Medical Director Dr. Marc Mora, whose leadership and support for creating an optometric residency program helped bring us to this point,” adds Dr. Paros. “Our vision is to be the best primary care optometric residency program in the nation. Cultivating new optometrists as residents gives us the sustainability to fulfill that vision.”

Questions or comments? Respond to Open Mike

Kaye Kvam, PA-C has become a member of a select group of outstanding physician assistants who have distinguished themselves among their colleagues, as well as in their communities. AAPA Distinguished Fellows are recognized for service to their profession, their commitment to advancing health care for all people, and by their exemplary personal and professional development.

Congratulations to Kaye Kvam, PA-C, and now, DFAAPA: Distinguished Fellow, American Academy of Physician Assistants.

Questions or comments? Respond to Open Mike

A patient of Capitol Hill Family Medicine physician Noah Silver, MD, recently wrote to share her experience in pain relief, and to thank the medical team and staff who contributed to her Group Health experience.

She writes:

Dear Noah-
I wanted you, my doctor, for whom I have the utmost respect and great fondness, to let you know that I had the epidural injection this afternoon. I awoke and sat up in bed tonight—and for the first time in over a month felt no pain whatsoever. Those words bring tears to my eyes even now: on a scale of 0 to 10, I was a 0. I am going to go back to bed. I will try to schedule a phone consultation with you tomorrow morning…My dear friend and I went to Tukwila this morning and met with Shelley Campanella and then Lisa Valentijn They were intelligent, knowledgeable, responsive, and compassionate to the utmost degree and down to the smallest detail. 

Dr. Steven Levine later addressed our questions about the injection, sharing with us his knowledge, and the limits of that knowledge. I am 105 percent satisfied with the care I received at Group Health today. I believe we have made considerable progress toward licking this problem. I am confident that in working with people like you, Dr. Noah Silver, Shelley Campanella, Lisa Valentijn, and Dr. Steven Levine, I am working with the A-team. 

And, in a follow-up e-mail to Lisa Valentijn, Supervisor, Customer Contact Center and Shelley Campanella, Manager, Customer Service (CBRE Facilities):

…I felt not only listened to but heard, and the way you both expressed that was by immediate intelligent responsive action as well as your kind words and considerate demeanor. I will forever remember and bless you both: please know that you two inspired me as living proof of what a difference caring, committed, knowledgeable health care workers can make, have made. 

Group Health is very fortunate to have you two, Dr. Silver, and Dr. Levine among its employees. I hope you all receive acknowledgment from your organization. Please share this letter with anyone you wish.

Bless you.

Questions or comments? Respond to Open Mike

The Group Health Foundation's Fund for Tomorrow's Medical Leaders is designed to “encourage, stimulate, and help develop young physicians with a high potential to become strong, effective, courageous, innovative, and independent-thinking medical leaders of the future.”

The program, launched by gifts to the Tomorrow's Medical Leaders Endowed Fund from Group Health Cooperative, Group Health Foundation, and Dr. Howard and Stephanie Kirz, continues to be supported by regular contributions from individual donors.

Each year the Tomorrow's Medical Leaders program recognizes future leaders by providing grants of $10,000. Grants can be used on a wide range of professional development projects aligned with Group Health's strategic direction and promotion of innovation in health care.

Two $10,000 grants will be awarded to two grantees in 2010. Grant recipients have one year from the date of the award to use the funds.

Nomination and Award Process
Candidates must be physicians nominated by fellow GHP medical staff. Nominees will be asked to write a brief proposal responding to the question, “How would this award help you enhance your leadership skills?”

Nomination forms are due by September 1, 2010

Candidates will then be interviewed by a committee of GHP and Group Health Foundation leaders.

Award Criteria
The Tomorrow's Medical Leaders Annual Award may be awarded to any physician who consistently demonstrates influential qualities:

• Courageous leadership
• Innovative and independent thinking
• Ability to motivate others

2009 recipient Wellesley Chapman, MD, is using his grant award to develop a Lean culture at Burien Medical Center, with emphasis on visual tools and A3 Thinking. “This financial resource helps us explore and develop new ways of working that benefit us all,” says Chapman. “Spare funds in our system are hard to come by. Support from the Foundation has allowed the Burien clinic to create a space to learn and experiment.”

Questions or comments? Respond to Open Mike