U.S. Office of Personnel Management - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

Our Vision for Patient Safety at Kaiser Permanente

Kaiser Permanente Northern California is committed to remaining a national leader in patient safety, and becoming the safest place to give and receive care in California, the nation, or the world.

Mission Statement

As an integral part of the organization's Quality Program, patient safety requires providing patient centered care that is reliable, effective, consistent, and safe. This mission is founded on a philosophy that believes patient safety is every patient's right and every leader’s, employee’s, physician’s and patient’s responsibility. It is an ongoing and relentless commitment to build safer systems, using performance improvement methodology, and prevent the preventable.

Guiding Values

The values that guide patient safety planning, implementation, and decision-making at Kaiser Permanente are patient-centeredness, reliability, and transparency.

Objectives

The principles that promote excellent performance in the safe and effective delivery of health care are awareness, accountability, ability, and action. Activities that are aligned with these principles are implemented broadly and aimed at ongoing achievement of the following objectives:

• A strong and unified patient safety culture, with patient safety embraced as a shared value.
• An environment of accountability that encourages responsible reporting of near misses and errors and that looks to improve systems and not individual blame.
• A measurement strategy that identifies harm and provides meaningful feedback on system performance and improvement activities
• A proactive performance improvement process that prevents failure, identifies and mitigates hazards, and redesigns systems and processes to improve reliability
• A prioritization process that optimizes the allocation of resources in the implementation of patient safety performance improvement strategies
• Ongoing identification, sharing, and appropriate implementation of successful practices from other parts of the organization, other healthcare organizations, and organizations outside of healthcare
• Ongoing patient safety and error prevention training and education for individuals and teams throughout the organization
• Engaging the patient as a partner in safety
• Developing new knowledge and understanding of patient and workplace safety in the delivery system
• Identifying, assessing, and implementing the most appropriate indicators and measures of safety
• Using Performance Improvement methodology as the method to improve identified patient safety issues.

Strategic Themes

To permeate responsibility and mutual accountability for patient safety throughout our organization, Kaiser Permanente will continue to implement activities broadly aimed at becoming a highly reliable organization by achieving the following six strategic themes:

The foundational elements of all patient safety initiatives and activities at Kaiser Permanente will continue to be:

1. An understanding of human error and human factors;
2. The creation and maintenance of a culture in which reporting takes place in a "just culture"
3. A learning organization
4. The application of reliability theory to continually improve safe practice
5. Seeking input from and collaborating with patients and families
6. Assuring compliance with all of the state, and national regulatory standards supporting Patient Safety

2012 Focus Areas

Based on the evaluation of prior patient safety plans, assessment of external drivers (including clinical evidence, legislation, regulations, accreditation, and employer focus), review of recent KP experience and data, and input from key stakeholders, patient safety focus areas for 2012 patient safety initiatives are briefly described below.

Highly Reliable Surgical Teams (HRST):
The concept of high reliability organizations comes from the study of highly complex and hazardous operations such as airline flight operations. A Highly Reliable Surgical Team is one in which the performance of high risk activities is the norm, but accident or harm rates are low. The program was developed and rolled out across KP in 2006. We continue to spread regional learning and apply research findings to improve surgical safety. Improve regional reporting of never events. Analyze trends and issues in surgical never events, design solution to address system issues and reduce surgical never events.

National Surgical Quality Improvement Program (NSQIP):
The National Surgical Quality Improvement Project (NSQIP) of the American College of Surgeons provides risk adjusted surgical outcomes measures for participating hospitals that can be used for performance improvement of surgical mortality and morbidity. All 21 NCAL KP facilities participate. Lead participation in the American College of Surgeon’s surgical outcome reporting data base. We use non-risk adjusted and risk adjusted outcomes to identify opportunities for performance improvement to reduce surgical complications. Support Regional PI initiatives using the KP PI Model, currently working to reduce Colorectal SSI Infections.

Highly Reliable Procedure teams (HRPT):
The concept of high reliability organizations comes from the study of highly complex and hazardous operations such as airline flight operations. Plan to expand this based on the HRO literature and Comprehensive Unit Safety Program (CUSP) model from Peter Provonost, We plan to develop a systematic approach to reduce errors and improve safety in procedural and patient care areas, including but not limited to radiology, and other high risk areas.

National Patient Safety Goals (NPSG):
In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program; the first set of NPSGs was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety. A panel of widely recognized patient safety experts advise the Joint Commission on the development and updating of NPSGs. This panel, called the Patient Safety Advisory Group, is composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. Lead work aimed at ensuring compliance with patient safety regulations and standards such as Joint Commission, NCQA, NQF, CMS, IHI, AHRQ and KP National Quality Review. We raise staff awareness to assure simultaneous understanding and operational application of the goals as they pertain to general and specific patient populations. Analyze trends over time and evaluate the impact of patient safety initiatives and interventions.

High Alert Medication Program (HAMP):
Kaiser Permanente introduced the High Alert Medication Program in 2005 to eliminate errors associated with specific high-risk medications – medications where an error carries a high risk of injury or death. Kaiser Permanente Northern California physicians, nurses, pharmacists, quality leaders, and labor unions worked with regional and local medication safety committees to originally identify 17 high-risk, problem-prone drugs and drug classes and implement standard handling practices for them in every care setting. The list has now grown to 22 including more than 91 different medications. These practices, which have been adopted at Kaiser Permanente facilities across the country, include separate storage, high-alert labeling, new packaging, standardized handling, checks and double-checks, and technologies that ensure accurate doses, such as “smart pumps” for IVs and gurney scales in Emergency Departments. We continually evaluate and develop programs to reduce medication errors through the whole healthcare continuum. Support ongoing implementation and evaluation of the High Alert Medication Program across all regions.

Anticoagulation Safety
As part of the HAMP program, Heparin infusions have proven to be the most common error reported. We use Responsible Reporting data to identify opportunities for performance improvement to reduce IV heparin errors. Partner with Regional Pharmacy and patient Care Services to evaluate systems that can support safe heparin administration.

Safety Attitude Questionnaire (SAQ):
The safety of patients in hospitals has become an issue of concern for providers, patients, staff, and health care leaders over the last decade. One approach in improving patient safety is by focusing on the organization’s patient safety culture. Safety culture is the result of individual and group values, attitudes, perceptions, and patterns of behavior that determine the commitment to an organizations’ safety management (Sexton, 2006). The Safety Attitudes Questionnaire (SAQ) is one tool that is used to elicit the perceptions of staff about the patient safety culture in their work unit or department. It also provides a ‘snapshot’ of the culture of the workplace, offering insights into the contexts of patient care. Our goal is to drive culture throughout the organization by using a survey tool to gain a greater awareness of the culture of safety. In keeping with the goal of achieving World Class Hospital status, Regional medical centers will be surveyed on a regular basis. Results will be analyzed, staff debriefed, and action plans developed. The measure of improvement will be the re administration of the SAQ.

Just Culture:
A Just Culture is a culture of accountability that supports reporting; doesn’t advocate name, blame, shame, and train; does advocate for fair treatment, based on trust; and has intolerance for reckless behavior. In a Just Culture people are treated fairly when an error occurs but there is a clear line between acceptable and unacceptable behavior. We continue to provide education and training regarding a just culture through the PSU and other venues. We plan to pilot the use of the automated algorithm and begin spread process. We support leaders and managers utilize the just culture algorithm by providing consultation through the Regional Just Culture Advisory Board.

Patient and Family Centered Care:
PFCC is an approach to the planning, delivery and evaluation of health care that is grounded in mutually beneficial partnerships among patients, families, and healthcare practitioners. The ultimate goal of PFCC is to create partnerships among healthcare practitioners, patients and families that will lead to the best outcomes and enhance the quality and safety of health care.1. Patient and Family Centered Care means determining from the perspective of patients and families the adequacy of all aspects of the care delivery process. We provide consultation to medical centers related to the development of patient advisory councils In order to continually embrace the concepts of patient and Family Centered care (including patients at all levels of the organization). We support Nurse Knowledge Exchange and other initiatives which involve patients and family in setting care goals, teach-backs (literacy and understanding), and informed consent.

Health Literacy:
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. At least 48% of the population of the United States has difficulty understanding both verbal and written healthcare information. We continue to lead efforts to ensure that health literacy is considered in programs, projects, initiatives, and written materials that directly impact the patient e.g. health education materials, medication information, transitions in care work, etc.

Patient Safety University(PSU):
PSU-1The Patient Safety University (PSU) is an intense two day program for Kaiser Permanent leadership (KFH/P and TPMG). The purpose of this two day program is to provide leadership with the information and tools necessary to provide leadership and support to the development of a culture of safety throughout the organization as well as individual medical centers The program is aimed at creating the safest care system and is a necessary component of reaching the aim of being a World Class Healthcare Organization.

PSU-2 is a four hour program aimed at direct care staff and physicians. This program relies on a three pronged approach:

1. Building a culture of safety for the care team and environment
2. Building skills in teamwork and communication
3. Insuring that daily work that has an evidence base is reliably delivered

Safe Products and Devices:
In order to assure systems of safety, we participate in reviews of new technologies and devices, to identify and avoiding latent conditions which may impact patient safety, e.g. preventing tubing misconnections.

Leapfrog Survey:
The Leapfrog Survey grew out of a 1999 report by the Institute of Medicine named "To Err is Human" and was developed by the Leapfrog Group, an initiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare. Annually the Group releases a survey for hospitals to complete. The Survey is released publicly and is aimed at ensuring that employer purchasing groups make informed decisions when choosing a hospital or plan. Our role at Regional Patient Safety is to ensure ongoing survey readiness with local Kaiser Permanente hospitals, development of systems and tools to improve performance and timely submission of Northern California hospital surveys to the Leapfrog Group. We also assist local hospitals in achieving Leapfrog “Top Hospital Distinction” as a mark of national excellence in healthcare.

Hospital and Emergency Department Reliability and Operational Excellence for Safety (HEROES) Collaborative:
The HEROES Collaborative was established in 2007 to implement performance improvement in the areas of early awareness of patient deterioration and early rescue (Rapid Response Teams), decreasing the incidence of hospital acquired pressure ulcers, and decreasing the incidence of patient falls and falls with injury. In 2010, improving the reliability of hand hygiene and isolation practices to prevent the spread of infection was added to HEROES. The 2012 focus for the HEROES Collaborative has been decreasing the incidence and severity of patient falls in the hospital through the implementation of interventions targeted at patients who are at a high risk for a fall related injury (Age > 85, fragile bones, anti-coagulated, or first 24 hours following surgery).

Perinatal Patient Safety Program:
The NCAL Regional Perinatal Patient Safety Program (PPSP) has a long history of providing guidance to improve and support perinatal patient safety initiatives since 2001. Simulation training has been a big component in creating high reliability perinatal units by multidisciplinary training and scenarios for emergent cesarean section, shoulder dystocia, maternal hemorrhage, and maternal collapse emergencies. PPSP most recent efforts have been to standard collaborative practice agreements and algorithms for fetal heart interpretation and obstetrical emergencies with spread all 14 perinatal units.