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Henry Ford Health System’s ‘No Harm Campaign’ Reduces Harm and Saves Lives

The “No Harm Campaign” at Henry Ford Health System (HFHS) in Detroit integrates national, local, and homegrown efforts into one system-wide initiative to reduce harm. With an ambitious goal to decrease harm events system-wide by 50% from 2008-2013, the No Harm Campaign focuses on enhancing the culture of safety, improving the quality and clarity of clinical communications, identifying top causes of harm overall and at individual points on the continuum of care, and redesigning care to eliminate common causes of harm.

HFHS uses a broad definition of harm: any unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital.

Harm reduction is measured by a comprehensive set of 27 measures across six categories: infection-related, medication-related, procedure-related, care delivery, employee, and other types of harm. These harm measures, comprised of hundreds of medical codes, combine to create a unique aggregate global harm score. The global harm score for each hospital overall and by category is transparent to all stakeholders within the system in an effort to create and spread best practices for harm reduction across the system.

From January 2008 through December 2011, the combined inpatient harm rate system-wide decreased by 31% and system-wide mortality rate decreased by 18%. This reflects a reduction of 169 harm events/month even while adding a new hospital and increasing the total number of patient days in the period measured. Cost-savings of the No Harm Campaign are estimated to total $10 million over a 4-year period, a savings of 8-9% each year in costs.

Read More

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

Henry Ford Task Force Reduces Catheter-related Bloodstream Infections in Hemodialysis Patients

The Henry Ford Medical Group in Detroit has a large dialysis program with high-risk patients; about 80 to 100 of these patients per month use a hemodialysis catheter for vascular access. Despite attempts to reduce catheter-related bloodstream infections (CRBSI) over a 3-year period, rates remained well above the national benchmark of 3.1/100 patient months. To address this issue, the Catheter Bacteremia Task Force was formed, involving Nephrology, Pharmacy Services, Infectious Diseases, Infection Control, and the Dialysis Administrator. This Task Force included the expertise and key leadership needed to make any potential intervention successful. The protocol involved instilling a gentamicin/trisodium citrate solution into the catheter lumen after each patient’s dialysis session.

Use of the antibiotic lock protocol decreased the average rate of CRBSI by almost 85%, avoiding an estimated 69 infections. The protocol was spread to three other dialysis units, resulting in a 24.5% reduction in mortality for dialysis patients. This improvement initiative reduced infections to below the national benchmark and reduced hospitalizations and unnecessary vascular access procedures which also translated into significant cost-savings.

For this innovative work, Henry Ford Health System won the Innovations in Healthcare Award in recognition of excellence in chronic kidney disease prevention and treatment.

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

Improving Care and Reducing Costs for PPO Patients: HealthCare Partners ACO Pilot Program

In 2009, Brookings–Dartmouth launched its ACO Pilot Program to support four provider groups to form accountable care organizations (ACOs) with health plans and private payers (as opposed to the Medicare government-supported ACO programs now underway). The provider organizations that are participating all agreed to take responsibility for the overall cost and quality of care for their patients, with their private payer partner.

The chosen organizations are HealthCare Partners, a medical group/independent practice association (IPA) based in Los Angeles, CA.; Monarch HealthCare, an IPA in Orange County, CA; Norton Healthcare, an integrated delivery system in Louisville, KY; and Tucson Medical Center, a community hospital working with independent provider groups in Tucson, AZ.

This preliminary case study conducted by the Commonwealth Fund with Brookings-Dartmouth describes the HealthCare Partners’ experience to date.


Improving Care and Reducing Costs for PPO Patients: HealthCare Partners’ Brookings–Dartmouth ACO Pilot Program

HealthCare Partners, Los Angeles, California

In 2009, Brookings–Dartmouth launched its ACO Pilot Program to support four provider groups to form accountable care organizations (ACOs) with health plans and private payers (as opposed to the Medicare government-supported ACO programs now underway). The provider organizations that are participating all agreed to take responsibility for the overall cost and quality of care for their patients, with their private payer partner.

The organizations chosen are HealthCare Partners, a medical group/independent practice association (IPA) based in Los Angeles, CA.; Monarch HealthCare, an IPA in Orange County, CA; Norton Healthcare, an integrated delivery system in Louisville, KY; and Tucson Medical Center, a community hospital working with independent provider groups in Tucson, AZ.

This preliminary case study conducted by the Commonwealth Fund with Brookings-Dartmouth describes the HealthCare Partners’ (HCP) experience to date. In this report, the researchers reveal the characteristics of HCP and its partner organizations, including Anthem, the payer partner; the organization’s decision to develop an ACO; the steps that HCP has taken to implement the model; as well as the achievements and lessons learned as of this writing.

This report discusses how HCP’s success thus far is attributable to its strong primary care base; culture of accountability; emphasis on prevention and promotion; sophisticated integrated health information technology; care management and care coordination processes; performance measurement and reporting; and experience with risk-based contracts with payers.

For the complete report, please click here.

For a complete list of case studies in this Commonwealth Fund series, along with an introduction and description of methods, please click here.

FOR MORE INFORMATION:

Robert Klein
HealthCare Partners
VP Communications and Marketing
310-630-4126
rjklein@healthcarepartners.com
www.healthcarepartners.com

Virginia Mason Provider-Employer-Payer Collaboratives Target Common Medical Conditions

Virginia Mason Medical Center in Seattle has worked in collaboration with health plans and employers to develop standardized approaches to the care of patients with common medical conditions. Called marketplace collaboratives, these efforts have eliminated unnecessary treatment and decreased costs to employers, health plans, patients, and providers while improving quality and value. To date, Virginia Mason has implemented clinical value streams for low back pain, headache, large joint pain, and breast concerns not related to cancer screening. The strides made in quality by this approach have been impressive.


Excerpted from:

At Virginia Mason, Collaboration Among Providers, Employers, and Health Plans to Transform Care Cut Costs and Improved Quality, by C. Craig Blackmore, Robert S. Mecklenburg, and Gary S. Kaplan

http://content.healthaffairs.org/content/30/9/1680.full.html

Virginia Mason Medical Center in Seattle has worked in collaboration with health plans and employers to develop standardized approaches to the care of patients with common medical conditions. Called marketplace collaboratives, these efforts have eliminated unnecessary treatment and decreased costs to employers, health plans, patients, and providers while improving quality and value.

The initial task of the first marketplace collaborative was to define quality. After much deliberation, the collaborative participants decided that quality related to five key factors: patient satisfaction; the practice of evidence-based care; rapid access to care by patients; patients’ rapid return to functioning; and cost. Once the definition of quality was determined, the next step was to identify the optimal, evidence-based care for low back pain, the focus of the first collaborative. Each subsequent marketplace collaborative has selected a different condition to target for improvement. Called “clinical value streams,” these standardized clinical pathways ensure that best practices are followed and unnecessary test and treatments are eliminated.

To date, Virginia Mason has implemented clinical value streams for low back pain, headache, large joint pain, and breast concerns not related to cancer screening. The strides made in quality by this approach have been impressive. For instance, the headache clinical value stream focused on patients with uncomplicated headache in which no other symptoms of concern were present, such as head trauma or fever. These patients typically do not require expensive imaging tests, but many were receiving them anyway. Through the collaborative process, Virginia Mason decreased the use of MRIs by 23 percent, so delays in seeing a doctor because of pending test results were minimized. New policies were implemented that allowed patients to get in to see a doctor the same day as their headache developed in 95 percent of cases. The result has been that patients with headache now score their care at an impressive 91 in terms of patient satisfaction.

At Virginia Mason, collaborative efforts among providers, payers, and employers have lead to improved care delivery according to a common definition of quality. By developing and implementing evidence-based care pathways, quality parameters are being achieved by a decrease in unnecessary care and costs, and with high patient satisfaction and rapid access.

Keywords: access, evidence-based care, clinical pathways, headache, large joint pain, low back pain, quality improvement, payer collaboration, employer collaboration, clinical value streams, marketplace collaborative, Virginia Mason Medical Center, Seattle, Washington.

FOR MORE INFORMATION:

Michelle Peterson
Director, Communications and Public Relations
Virginia Mason Medical Center
100 Ninth Ave, MS GB-ADM
Seattle, WA 98101
(206) 583-6581
michelle.peterson@vmmc.org
http://www.VirginiaMason.org/

Integrating Independent Physicians into an Accountable Care Organization

Keywords: Advocate Physician Partners, Advocate Health Care, accountable care organizations, asthma, care coordination, care management, Illinois, intensive care, independent physician associations, performance improvement, prevention, physician and hospital collaboration, value

Advocate Physician Partners, a joint venture representing approximately 3,500 physicians serving patients in Illinois, could serve as a model for a new kind of ACO. Advocate Physician Partners is affiliated with Advocate Health Care, a not-for-profit faith-based health system in northern and central Illinois. By organizing physicians into partnerships with hospitals to improve care and be held accountable for the results, Advocate Physician Partners has addressed the most significant barriers to creating an effective ACO, and has also has made impressive strides in quality and outcomes.


A Model for Integrating Independent Physicians into Accountable Care Organizations

The online version of this article by Mark C. Shields, Pankaj H. Patel, Martin Manning, and Lee Sacks is available at:

http://content.healthaffairs.org/content/30/1/161.full.html

The Affordable Care Act encourages the formation of accountable care organizations (ACO) as a new part of Medicare. At this point, however, it is unclear precisely how these ACOs will be structured. Although large integrated care systems that directly employ physicians may be most likely to evolve into ACOs, few of these truly integrated systems exist in the United States.

Advocate Physician Partners, a joint venture representing approximately 3,500 independent physicians serving patients in Illinois, could serve as a model for a new kind of ACO. Advocate Physician Partners is affiliated with Advocate Health Care, a not-for-profit faith-based health system in northern and central Illinois. For more than fifteen years, the partnership between physicians and Advocate has performed care management and managed care contracting. By organizing physicians into partnerships with hospitals to improve care and be held accountable for the results, Advocate Physician Partners has addressed the most significant barriers to creating an effective ACO. It has also has made impressive strides in quality and outcomes.

Advocate Health Care hospitals invested more than $10 million in the technology of a centralized command center for all 250 adult intensive care beds in eight of its ten acute care hospitals. Staffed around the clock by board-certified intensivists, the initiative allows these specialists to make immediate changes in patients’ treatment based their condition, without waiting for the approval of attending physicians. In this way, new drugs, procedures, or therapies can be applied immediately, without delays. As a result, mortality for adult intensive care patients has decreased steadily since the program was implemented in 2003.

As part of a comprehensive program for care of asthma patients, the partnership has implemented standardized asthma action plans for home management, individualized for specific patients. In 2009, the partnership implemented action plans for 83 percent of its asthma patients. This number was three times greater than the national average, according to a study that showed only 26 percent of controlled asthma patients and 35 percent of uncontrolled asthma patients received such a plan from their physicians. And the partnership’s results typically exceed the National Committee for Quality Assurance’s measures for management of blood sugar, cholesterol, and blood pressure.

FOR MORE INFORMATION:

Nancy Taylor
Executive Director
Council of Accountable Physician Practices
|nancy.taylor@amga-capp.org
www.amga-capp.org

HealthPartners: Closing the Gap in Health Care Disparities (Colorectal Cancer)

Colorectal cancer deaths are 48 percent higher among African-Americans than among whites, according to the US Department of Health & Human Services. As a result, HealthPartners developed customized interventions aimed at reducing disparities in colorectal cancer screening rates for African-American patients.


More than ten years ago, HealthPartners began groundbreaking work to close a gap in health care and ensure that care and service is of equally high quality for all populations, regardless of a patient’s race or ethnicity, preferred language, private insurance or public program. To identify and address these disparities, HealthPartners leaders established the Cross Cultural Care and Service Task Force in 2001, and, in 2003, the health system developed a plan to collect self-reported patient demographic data to assist in creating strategies and tactics to improve care and service for our patients.

Reduction of colorectal cancer screening disparities for African-American patients

Colorectal cancer deaths are 48 percent higher among African-Americans than among whites, according to the US Department of Health & Human Services. As a result, HealthPartners developed customized interventions aimed at reducing disparities in colorectal cancer screening rates for African-American patients.

In 2009, based on new national guidelines and guidelines from the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative, HealthPartners expanded the eligible population for colorectal cancer screening to include African-Americans and Native Americans at age 45 instead of 50, which added more than 1,000 HealthPartners patients who needed screening.

To screen additional patients and to close the gap, HealthPartners developed several customized interventions, including:

  • Using the race information provided by patients and the electronic medical record to automatically generate reminders to African-American and Native American patients and providers to have colorectal screening beginning at age 45
  • Telephone outreach to patients who were eligible for screening
  • The option of a fecal immunochemical (FIT) test, an evidence-based alternative to colonoscopy. The electronic medical record provides a shared decision making tool for our provider to offer the FIT test for patients who prefer it over colonoscopy.

These interventions are saving lives by improving screening disparities by payer (as a measure of socioeconomic differences) and by race. HealthPartners has seen a 27 percent improvement in colorectal screening rates for African American patients since implementation. Even with the population expansion, HealthPartners screening rates continue to rise rapidly, and are already above the 2010 HEDIS 50th percentile rankings.

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Intensive Primary Care Program Achieves Better Outcomes for Virginia Mason Patients

Patients with complex health needs such as diabetes, hypertension, coronary artery disease and other chronic health conditions require specializied medical attention. Care for such patients is typically uncoordinated, which often results in costly and frequent services. Recognizing this, Virginia Mason Medical Center developed an innovate primary care program for this population that has resulted in better health outcomes and increased satisfaction at a lower cost.


Longer version:

Virginia Mason developed an innovative primary care program for patients with complex health needs such as diabetes, hypertension, coronary artery disease and other chronic health conditions. The Intensive Primary Care program provides focused, coordinated care for patients, resulting in better health outcomes and increased satisfaction at a lower cost. Certain patients may choose to participate, receiving care from their primary care physician, nurse care manager, and supporting care team members who provide proactive outreach, continuity of care, and support to participants via e-mail, phone, and in-person visits.

Care for patients with chronic and complex conditions is typically uncoordinated, which often results in costly and frequent services. This program provides a highly individualized and accessible form of enhanced primary care, based on treatment goals specific to each patient.

The program had its origins in a pilot, initiated by The Boeing Company, that Virginia Mason and Regence BlueShield participated in from 2007 to 2009. The pilot achieved positive results in patients’ health, functional status, and satisfaction with care. It also helped reduce health costs by more than 20 percent, primarily by decreasing hospital admissions and emergency room visits. The pilot focused on 750 Boeing employees who suffered from complex health issues, such as hypertension, diabetes, heart problems and depression.

Virginia Mason and Regence BlueShield recognize the need for health care reform, and believe that many of the answers lie in partnerships such as this. By working together, this helath care provider and insurer are demonstrating that positive change is possible — that the quality of the health care experience for patients can be improved by providing the appropriate treatments at the right time at the right cost.

The program is based on research and design work conducted by national health care improvement specialists and draws from similar new primary care models advocated by the American College of Physicians and the American Academy of Family Practitioners.

Keywords: care teams, complex health needs, chronic care management, Intensive Primary Care program, Boeing, Regence BlueShield, hospital readmissions, increased patient satisfaction, treatment goals, value, Virginia Mason Medical Center, Washington

For More Information:

Michelle Peterson
Director, Communications and Public Relations
Virginia Mason Medical Center
100 Ninth Ave, MS GB-ADM
Seattle, WA 98101
(206) 583-6581
michelle.peterson@vmmc.org
http://www.VirginiaMason.org/

Virginia Mason’s Hospital Team Reduces Bedsores and Costs

Hospital-acquired pressure ulcers (HAPU), commonly known as bedsores, are increasingly common in hospitalized patients. To address this issue at Virginia Mason, the Zero Hospital-Acquired Pressure Ulcers team was established. The team reviewed guidance materials and brainstormed how to improve the HAPU program already in place at VM. They used the tools of the Virginia Mason Production System. They streamlined the display of the wound/skin assessment forms on the electronic medical record so a patient’s skin status is more apparent. VM recently celebrated 298 days since its last incidence of Stage 3-4 HAPU (the most serious form of bedsore), and their work met the Leapfrog Group’s high standards for reducing preventable medical errors in hospitals.


Virginia Mason’s Hospital Team Reduces Bedsores and Costs

Despite great technological and pharmacological leaps in health care in recent years, hospitals continue to struggle with the problem of hospital-acquired pressure ulcers (HAPU), commonly known as bedsores. These wounds are increasingly common in hospitalized patients, with approximately 600,000 acute care patients dying each year of HAPU complications at an estimated cost of $11 billion.

To address this issue at Virginia Mason, the Zero Hospital-Acquired Pressure Ulcers team was established. The need to reduce the incidence of pressure ulcers at Virginia Mason Hospital was clear. In 2007, the organization reported five Stage 3-4 HAPUs (the most serious type) to the Washington State Department of Health and treated many more Stage 1-2 HAPU with expensive therapies and extra days of hospitalization. The work began in the highest-risk setting for HAPU, the Critical Care Unit. The team implemented a systematic approach to identifying patients at risk of developing HAPU and established standard actions for at-risk patients. As these standards proved successful they were spread to other units. As a result, VM now stands in the top-performing group nationally for averting HAPU injuries.

How it was done.The team began by reviewing guidance materials from national groups and brainstormed how to improve the HAPU program already in place at VM. They used the tools of the Virginia Mason Production System. They streamlined the display of the wound/skin assessment forms on the electronic medical record (Cerner) so that a patient’s skin status is more apparent, which helps staff more easily identify at-risk patients who need more frequent position changes and meticulous skin care.

The team’s key strategy focused on enhancing the inspection process of patients. Inspection can lead to early, preventive action such as implementing a SKIN bundle (Surface, Keep turning, Incontinence, Nutrition) or asking for help from a wound/skin expert. In addition to developing all nurses’ HAPU-prevention competencies, the team also made advanced wound expertise more readily available on units. VM recently celebrated 298 days since its last Stage 3-4 HAPU.

Keywords: Bedsores, care teams, costs of HAPU, Cerner CPOE, Critical Care Unit, electronic medical record, EMR, hospital-acquired pressure ulcers, HAPU, Leapfrog Group, preventable medical error, skin inspection, Stage 3-4 HAPU, value, Virginia Mason Production System

For More Information:

Michelle Peterson
Director, Communications and Public Relations
Virginia Mason Medical Center
100 Ninth Ave, MS GB-ADM
Seattle, WA 98101
(206) 583-6581
michelle.peterson@vmmc.org
http://www.VirginiaMason.org/

Improving Quality and Reducing Waste: The Virginia Mason Production System

The Virginia Mason Production System (VMPS) is a management method that seeks to continually improve how work is done within the medical center. Using this method, Virginia Mason (VM) identifies and eliminates waste and inefficiency in the many work processes that are part of the health care experience, making it possible for VM staff to deliver the highest quality and safest patient care. By streamlining repetitive and low-touch aspects of care delivery, staff members are freed to spend more time talking with, listening to and treat­ing patients. Using this methodology, VM has successfully implemented many improvements in their medical center.

The patient safety alert system at Virginia Mason, for example, has created a culture in which safety problems are quickly identified and addressed, increasing patient safety at the medical center and decreasing medical claims.VM nursing teams used VMPS to redesign their flow of work so they could focus more on patient care, and hospital emergency staff created a process that allows the team to treat more patients faster and with more efficiency.


Longer version:

Adopting VMPS in 2001 required a paradigm shift from thinking errors, inefficiencies and defects are to be expected, to believing that achieving zero defects in health care is not only possible, but also urgently necessary. VMPS uses a variety of strategies to accomplish the elimination of defects and waste, but all begin with an understanding that the medical staff who do the work know what the problems are and have the best solutions. Staff work together in one- to five-day workshops and events to brainstorm, test and implement improvement ideas. Long-term follow up ensures that changes are ingrained into the work and are actually used by the staff. Successes include:

Patient Safety Alert System.
VM used VMPS principles to develop a Patient Safety Alert (PSA) system requiring all staff who encounter a situation likely to harm a patient to make an immediate report and “stop the line” (i.e., cease any activity that could cause further harm). Since the PSA system was implemented, patient safety at VM has increased, and medical claims have dropped.

Getting Back to Nursing.
VM nursing teams used VMPS to redesign the flow of work so they could focus more on patient care. Instead of caring for patients throughout a unit, nurses now work as a team with a patient-care technician (PCT) in “cells” (groups of rooms located near each other). The cell model made it easier for nurses to monitor patients and quickly attend to needs, and communicate with each other. This reduced the number of steps walked per day from 10,000 to roughly 1,200.

Express Treatment in the Emergency Department.
Emergency departments are a major entry point for hospitals and can be a bottleneck. ED patient care is typically more expensive and involves longer wait times. Using VMPS, the ED team at Virginia Mason learned to predict appropriate staffing levels for times of greatest demand. A “team sort” process using standard clinical assessment tools to quickly identify and sort patients’ care needs was implemented. Those requiring minimal services receive express treatment and are discharged without going to patient-care beds, creating capacity for patients who require more extensive services. This work helped Virginia Mason decrease the number of hours the ED was closed and unable to receive new patients by more than 90 percent over two years. In 2011, VM will move its ED into more efficient space and the team sort process will allow the team to care for more patients.

Keywords: Care teams, ED care, eliminating waste, emergency room care, patient safety alert, prevention, safety, value, Virginia Mason Medical Center, Virginia Mason Production System, work process improvement, zero defects

For More Information:

Michelle Peterson
Director, Communications and Public Relations
Virginia Mason Medical Center
100 Ninth Ave, MS GB-ADM
Seattle, WA 98101
(206) 583-6581
michelle.peterson@vmmc.org
http://www.VirginiaMason.org/

Kaiser Permanente’s Joint Replacement Registry Improves Patient Outcomes While Reducing Costs

Within the US, over 600,000 total hip and total knee replacements are performed each year. By the year 2030, that number is projected to exceed 4 million. Annual hospital costs associated with these procedures are projected to exceed $65 billion by 2015. The projected increases in the demand for total joint replacements and the costs associated with these procedures will challenge our already overburdened US health care system. Kaiser Permanante’s Total Joint Replacement Registry helps its surgeons and patients make informed decisions about which implant to use or in which patients the risks and potential costs of failure make surgery unwise.


Excerpted from The Permanente Journal article:

“Within the US, over 600,000 total hip and total knee replacements are performed each year. By the year 2030, that number is projected to exceed 4 million. Annual hospital costs associated with these procedures are projected to exceed $65 billion by 2015. Although patients who undergo total joint arthroplasty (TJA) are often of retirement age, recent studies have shown that patients below age 65 represent 35-45% of all TJA recipients in the US. As TJA is marketed more as a lifestyle operation than as a final option to retain mobility for end-stage arthritis, the proportion of patients below age 65 may increase.

The projected increases in TJA demand and the costs associated with these procedures will challenge our already overburdened US health care system. One potential method to address this pending crisis is through comparative safety and clinical effectiveness research aimed at reducing the need for TJA revision surgery. Registries are one example of clinical effectiveness studies that can help surgeons and patients make informed decisions about which implant to use or in which patients the risks and potential costs of failure make surgery unwise. These studies can also identify the relative value of TJA over alternative treatments or the effectiveness of one implant brand or design over another. Although implants vary widely in cost, there is little evidence to support the use of new, more expensive designs instead of more established, traditional designs.

The goals of the Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) are: 1) to monitor revision, failure, and rates of key complications (e.g., infection, venous thromboembolic disease such as blood clots and embolism, and mortality); 2) to identify patients at risk for poor clinical outcomes following TJA; 3) to identify the most effective techniques and implant devices (best practices and implant constructs); 4) to track implant usage and costs; and 5) to monitor and to support implant recalls and advisories in cooperation with the US Food and Drug Administration.”

Link to full journal article: http://xnet.kp.org/permanentejournal/sum08/joint-replacement.html

Keywords: clinical effectiveness, total hip replacements, total knee replacements, joint replacement, total joint replacement registry, total joint arthroplasty, TJA, Kaiser Permanente, KP, Southern California, registries

For More Information:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org