Health Policy$ense

That Kaiser ‘Special Sauce’ – Is It The Nurses?

The Importance of Nursing for Achieving Kaiser Quality

Not every health system can be Kaiser Permanente, but many try. Kaiser’s model of integrated health delivery is highly regarded for high-quality and efficient health care. But while many have tried to replicate this structural integration (perhaps without evidence of effectiveness?), could it be that the ‘secret sauce’ of Kaiser’s success is something else entirely?  A new study by LDI Senior Fellows Matthew McHugh and Linda Aiken, of Penn Nursing, and Lawton Burns, of Wharton, sheds light on whether the organization and work environment of nurses might account for some of that success.

McHugh and colleagues used a cross-sectional analysis of linked secondary data to assess differences between Kaiser and non-Kaiser hospitals in patient outcomes (such as patient mortality and failure-to-rescue) and nursing outcomes (such as nurse burnout, job satisfaction and intent-to-leave). They also compared Kaiser hospitals with Magnet hospitals, which are recognized for having excellent nurse work environments.

The authors find that patient and nurse outcomes in Kaiser hospitals are comparable to Magnet hospitals and significantly better than non-Magnet hospitals. Kaiser hospitals had better nurse work environments, staffing levels and a higher proportion of nurses with bachelor’s degrees, compared to non-Magnet hospitals.

Do these differences in nursing explain a significant proportion of the Kaiser outcomes advantage? According to McHugh and colleagues, yes. This study makes the case for investing in professional nursing and suggests that hospitals consider Magnet designation. They note that Magnet designation is a pathway to achieving a good work environment for nurses, but not the only one:

Ultimately, efforts that substantially improve nurses’ autonomy, provide nurses with control over their practice and resources, support consistent and adequate staffing, develop a highly educated workforce, encourage consistent managerial support, and support and expect excellent working relationships and communication between nurses and physicians can empower nurses to effectively provide the highest level of care and act on behalf of patients to ensure good outcomes.

That an important element of Kaiser’s success is its investment in nursing may not be evident to other health systems that are seeking to emulate the Kaiser model, but it’s potentially a more easily achievable aim than structural changes. This is in line with what Burns, one of the study’s authors and an expert on delivery integration, has written previously that: “…the logic of integration is more important than the structure of integration. Hospital system success may rest on capabilities such as leadership, culture, collaboration, and human resource management.”

McHugh and colleagues note that after controlling for other factors, Kaiser still had an advantage, even over Magnet hospitals, in terms of lower percentages of nurses reporting an intent to leave their job. They suggest this may be the result of additional factors they aren’t measuring that are part of the Kaiser culture and attractive to nurses. And there we are, back to that Kaiser ‘special sauce’, but at least this new study gets us one step closer to figuring it out.