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Achieving Kaiser Permanente quality

McHugh, Matthew D.; Aiken, Linda H.; Eckenhoff, Myra E.; Burns, Lawton R.

doi: 10.1097/HMR.0000000000000070

Background: The Kaiser Permanente model of integrated health delivery is highly regarded for high-quality and efficient health care. Efforts to reproduce Kaiser’s success have mostly failed. One factor that has received little attention and that could explain Kaiser’s advantage is its commitment to and investment in nursing as a key component of organizational culture and patient-centered care.

Purpose: The aim of this study was to investigate the role of Kaiser’s nursing organization in promoting quality of care.

Methodology: This was a cross-sectional analysis of linked secondary data from multiple sources, including a detailed survey of nurses, for 564 adult, general acute care hospitals from California, Florida, Pennsylvania, and New Jersey in 2006–2007. We used logistic regression models to examine whether patient (mortality and failure-to-rescue) and nurse (burnout, job satisfaction, and intent-to-leave) outcomes in Kaiser hospitals were better than in non-Kaiser hospitals. We then assessed whether differences in nursing explained outcomes differences between Kaiser and other hospitals. Finally, we examined whether Kaiser hospitals compared favorably with hospitals known for having excellent nurse work environments—Magnet hospitals.

Findings: Patient and nurse outcomes in Kaiser hospitals were significantly better compared with non-Magnet hospitals. Kaiser hospitals had significantly better nurse work environments, staffing levels, and more nurses with bachelor’s degrees. Differences in nursing explained a significant proportion of the Kaiser outcomes advantage. Kaiser hospital outcomes were comparable with Magnet hospitals, where better outcomes have been largely explained by differences in nursing.

Implications: An important element in Kaiser’s success is its investment in professional nursing, which may not be evident to systems seeking to achieve Kaiser’s advantage. Our results suggest that a possible strategy for achieving outcomes like Kaiser may be for hospitals to consider Magnet designation, a proven and cost-effective strategy to improve process of care through investments in nursing.

Matthew D. McHugh, PhD, JD, MPH, RN, FAAN, is The Rosemarie Greco Term Endowed Associate Professor in Advocacy, Center for Health Outcomes Policy Research, University of Pennsylvania, Philadelphia. E-mail:

Linda H. Aiken, PhD, RN, FAAN, is The Claire M. Fagin Leadership Professor of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia.

Myra E. Eckenhoff, BA, is a research assistant at theCenter for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia.

Lawton R. Burns, PhD, is James Joo-Jin Kim Professor, Wharton Center for Health Management and Economics, University of Pennsylvania, Philadelphia.

Funding for this study was provided by the National Institute of Nursing Research (R01-NR-004513, Aiken), the Robert Wood Johnson Foundation (Aiken), Kaiser Permanente (McHugh), and the Robert Wood Johnson Foundation Nurse Faculty Scholars program (McHugh).

An author (McHugh) has received funding from Kaiser Permanente; Kaiser Permanente had no input, review, or influence on this paper. The authors have disclosed no other significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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