Paul Wallace of Kaiser Permanente provided an overview of how Kaiser spreads research findings and chooses interventions for implementation. (See Appendix C for submitted responses.) The challenge is in balancing the tension between providing evidence-based care while providing care seen as relevant and important by both clinicians and patients. Kaiser operates in eight regions, giving rise to local issues, and provides care to 8.6 million members in a variety of settings. With hundreds of clinics, thousands of modules, tens of thousands of clinicians, and hundreds of thousands of employees, it is a challenge to balance both organized and “random acts” of quality improvement at the local level while implementing large national plans.
Kaiser Permanente is formally organized at both the national and regional levels. Certain core values are shared nationally and others locally. One national core value is the mutually exclusive relationship between Permanente medical groups and Kaiser health plans. Another core value is that all of Kaiser ’s physicians work for the Permanente Medical Groups and operate under capitated payment agreements with the Kaiser health plans, allowing for creative methods to pay for care innovations. The Permanente Medical Groups are multispecialty medical groups where specialists work closely with primary care physicians on a regular basis. Another national feature is Kaiser ’s overall governance, which includes a national board of directors for the health plan and an overall strategy developed jointly between the medical groups and health plan. One part of its national strategy is quality—including clinical quality, service, safety, and risk management. The Care Management Institute (CMI) was developed as a central place to share ideas about population-based care across regions. The CMI also houses formal networks for implementation and measurement.
Although consistent values are held nationally, organizational culture is largely a regional phenomenon, Wallace said. Each region and even each local office practices within its own locally evolved and defined culture. Locally, Kaiser ’s organizational cultures can largely be defined by regional medical groups that work together interregionally, but are considered separate entities running under separate budgets. The work of these medical groups is local, meaning in practical terms that “credit” for improvement is largely “owned” at the local level, despite the fact that Kaiser is a national organization.
Theoretically, ideas can flow through an organization either from the bottom up or from the top down. At Kaiser ideas flow in