A state agency has granted its highest possible rating to Kaiser Permanente for the fourth year in a row.

The designation comes from the Office of the Patient Advocate.

“Our model of care—based on prevention, coordination, integrated electronic medical records and prepayment rather than fee-for-service—creates a strong foundation for delivering high-quality, affordable and accessible health care,” said Gregory A. Adams, president of Kaiser Permanente Health Plan/Hospitals, Inc., in Northern California, according to a KP press release.