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The Kaiser Permanente Medical Care Program (Kaiser Permanente or Program), which includes Kaiser Foundation Health Plan, Inc. and its subsidiary Kaiser Foundation Health Plans (collectively "Health Plans"), Kaiser Foundation Hospitals, and the independent Permanente Medical Groups, arranges and provides prepaid comprehensive medical care to approximately 500,000 Federal members in 9 states and the District of Columbia. Kaiser Permanente has a fifty-year history of providing high quality comprehensive and cost-effective care to our members in the communities we serve. Our unique partnership with the Permanente Medical Groups has fostered the pursuit of clinical excellence. The result is clearly visible in the stature that Kaiser Permanente has attained as a national and regional leader in providing quality care.

Patient safety has always been a central focus of our national quality program. Our former chairman and CEO, David Lawrence, MD, whom departed in 2002 was a member of a committee that created the 1999 Institute of Medicine (IOM) Report and is a leading advocate for patient safety and revamping health care quality nationwide. Dr. Lawrence left a lasting positive impact on patient safety at Kaiser Permanente that continues on through a national strategic five-year plan for patient safety ("national plan"), developed in December 2000, based on a thorough external and internal assessment. This plan is updated on an annual basis based on evaluations of the previous year's work, as well as assessment of the current internal and external environment. Each Kaiser Permanente hHealth pPlan has developed a patient safety plan as part of their quality plan.

Many patient safety improvement programs have been implemented since the release of the IOM Report. These programs are aimed at achieving six strategic goals: safe culture, safe care, safe staff, safe support systems, safe place, and safe patients.

Accountability & Leadership

Responsibility and mutual accountability is fundamental to promote the safe and effective delivery of health care throughout Kaiser Permanente. Patient safety leaders have been appointed to provide continual oversight and coordination of our national agenda in California and in our Health Plans outside of California. With leadership commitment as our foundation, we are making progress towards becoming a national leader in patient safety. A Kaiser Permanente National Patient Safety Advisory Board has been appointed to provide ongoing perspective and guidance to the patient safety strategy, initiatives, and outcomes. Specific objectives include:

• Identify and address strategic opportunities to establish and maintain Kaiser Permanente's national patient safety leadership position.

• Support Kaiser Permanente's patient safety strategy and facilitate alignment and coordination of program-wide priorities and functions.

• Guide the vision, goals, priorities, and outcomes for regional and program office patient safety.

The Advisory Board consists of representatives from the regions as well as a representative from the Kaiser Permanente Labor Management Partnership.

Patient Safety Initiatives

Safe Culture - There are a number of national patient safety initiatives that address our goal of achieving a safe culture:

• Education and tools for developing a culture at KP in which staff and physicians openly report errors and near misses (a.k.a. “just culture”) has been promulgated nationally. This culture change is aimed at decreasing reliance on the traditional “blame and train” response strategy to error, thereby nurturing a non-punitive environment and enhancing accountability for safety. Multiple educational sessions on developing such a culture have been conducted. The initiative collaborates with Kaiser Permanente's Labor Management Partnership (LMP) to integrate a just culture framework into Issues Resolution and Corrective Action Processes, and with the Inter-regional Nursing Council to assess the pervasiveness of just culture concepts in patient care services.

• Safety Culture continues to be measured extensively throughout Kaiser Permanente using a tool adopted from the aviation industry (Safety Attitudes Questionnaire or SAQ) to assess teamwork, error detection, and incident response in the cockpit. The SAQ has been administered at each of over 20 pilot sites in order to obtain baseline data and measure attitude changes around team performance. Regions/Medical Centers involved in "Human Factors" pilots utilize these results not only to build a case for the importance of the intervention but also to have a process to monitor related outcomes.

• Kaiser Permanente has taken a significant step forward in establishing a national leadership position in communicating with patients and their families following unexpected clinical outcomes. In partnership with the Bayer Institute for Health Care Communication, a four-hour clinician-patient communication training program has been developed and is already being implemented across the Program. The initiative is guided by a set of core values and principles that guide these difficult communications. At the heart of these principles is acknowledgment of our responsibility and ethical obligation to communicate with our patients when unanticipated adverse outcomes have occurred, including an explanation of the outcome and its effects, provided in a timely, truthful, and compassionate manner.

Safe Care - Kaiser Permanente activities are aimed at preventing inpatient and outpatient medication errors and improving the overall quality of patient care.

• Baseline audits of inpatient and outpatient medication prescribing, dispensing, preparation, storage, administration, monitoring, and documentation processes have been completed. Action plans have been developed and implementation of prioritized areas has taken place.

• Implementation of medication error reduction initiatives developed by the Adverse Drug Event Prevention Project (ADEPP) is ongoing. Two major initiatives were completed in 2002, which include an educational series on Failure Mode and Effects Analysis (FMEA), Root Cause Analysis (RCA), and rapid cycle improvement, and the development of a model medication safety committee. Work continues on developing a strategy for high-alert medications identified by ADEPP, conducting outpatient medication safety assessments, and identifying other successful medication safety practices. Evaluation of the SMART-ordering program, implemented in 2001, indicates continued performance improvement.

• Interdisciplinary teams at all levels of the organization have been created to develop strategies to mitigate the risks of preventable adverse events. Examples of initiatives taking place at regional and medical center levels include reduction in misidentification errors leading to surgery on wrong site/part; improved consistency of timeliness of diagnosis; documentation of wound care; oversight of abnormal pap smear follow-up; communication of abnormal EKGs after ED visits; management of cardiac monitoring/telemetry systems; appropriate use of restraints; prevention of transfusion errors; falls prevention, and, prevention of nosocomial infections. Human factors pilot projects have been initiated to address areas including conducting team briefings before surgery, preventing patient falls, perinatal patient safety, and ensuring full transfer of information during handoffs. A dashboard of patient safety performance indicators is also being created by a subcommittee of the National Patient Safety Advisory Board to assist in measurement of structure, process, and clinical outcomes related to patient safety.

• Kaiser Permanente's patient safety efforts continue to be validated by the successful regional completion of relevant portions of the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys, as well as our internal barometer of Quality Assurance, the Medical Directors” Quality Review (MDQR). An inter-regional steering committee was formed to address the 2003 JCAHO national patient safety goals, from which recommended practices and procedures were disseminated.

Safe Staff - Kaiser Permanente seeks to ensure that staffs possess the knowledge and competence to safely perform required duties and improve system safety performance.

• The program remains committed to the education and training of staff in the area of patient safety, including specific education around human factors, systems safety, and building a culture of safety. In 2002, over 75% of all KP employees participated in and discussed the impact of an internally produced video, "Patient Safety: Every Patient's Right, Everyone's Responsibility." Patient Safety Executive Walkarounds are being piloted at two medical centers for the purpose of articulating leaderships' support of patient safety as well as soliciting patient safety concerns from staff and physicians. A staff/physician patient safety Newsletter (STEPS, “Sharing To Ensure Patient Safety”) was inaugurated in 2002 to share patient safety information throughout KP. This newsletter includes successful patient safety practices; information regarding legislation, external standards, and industry safety advancements; and articles/information of general interest in the area of patient safety.

• An online Patient Safety Compendium continues to be updated and reviewed as appropriate. To date, benchmarking the success of internal processes has identified 93 key practices and procedures related to patient safety from regions and medical centers across Kaiser Permanente. These practices, as well as the accompanying implementation tools, are available to all of our physicians and employees through KP's Intranet.

Safe Support Systems - We are committed to identifying, implementing, and maintaining support systems that provide the right information, to the right people, at the right time.

• The National Patient Safety website remains the primary source for successful practices, education, and information that support patient safety improvement and knowledge sharing. In addition to growing the online compendium of successful practices, a multitude of other tools to support patient safety communication, compliance/accreditation, and training is continuously being placed on the site as a vehicle for sharing regional safety insights, experience, and breakthroughs across the organization. The effectiveness of the website as a dissemination tool is assessed on a quarterly basis through traffic analysis and user groups, and adjustments are made to optimize the efficacy of the content.

• A process has been established to ensure that patient safety issues of interest emerging on the external horizon (e.g., proposed changes to legislation, innovations) are being identified, assessed, and communicated appropriately to regional stakeholders as well as being utilized to inform patient safety planning.

Safe Place - Kaiser Permanente is engaged in several initiatives that enhance the efficiency and effectiveness with which safe health care is provided.

• Kaiser Permanente is collaborating with the Disability Rights Advocates group to identify and remove architectural barriers to care, provide training and education to our physicians and employees to more effectively communicate and care for members with disabilities, and to review and appropriately modify related policies and procedures. By ensuring reasonable accommodations are consistently identified and implemented for our disabled population, we can assure these members the same level of safety and quality care as all members of the KP community.

• Through our Labor Management Partnership, union members and managers are working together toward a shared vision of creating a workplace free of injury. By providing a safe, supportive work environment for our staff, they can provide great care. There are currently over 10,000 Workers Compensation injuries filed at KP each year. The goal of the Workplace Safety Initiative is to achieve a 50% reduction in these injuries by the end of 2005. The infrastructure and groundwork to achieve this goal was established in 2002.

• Kaiser Permanente's National Product Safety Committee oversees the effective and efficient functioning of medical product and device recalls, as well as tracking internally identified product and device issues to closure. Working closely with our National Purchasing Department, the Product Safety Committee helps integrate safety into our purchasing decisions and works collaboratively with Purchasing when related issues do arise.

• Through the Templated Hospitals Project, patient safety principles are being incorporated into the design of all future Kaiser facilities. Input into this project has also been provided by experts in external organizations such as St. Joseph's in West Bend, Wisconsin, which convened a group of safety experts from around the country to come up with fundamental design principles to enhance patient safety, and Memorial Sloan-Kettering in New York City, which is studying the safe design of operating rooms.

Safe Patients - We are committed to educating all our members to understand their role in helping to prevent errors in their health care.

• Patient involvement in patient safety and creating member awareness continues to be an integral part of the patient safety agenda. Patient Safety information for KP members is available on KP's Internet site, and additionally is made available in member guidebooks, newsletters and brochures. Furthermore, patient partnership materials such as brochures and posters have been developed to further empower patients and encourage their active participation in safe outcomes.

• During the fall of 2002, focus groups were conducted in four regions in order to gain an understanding of how members view patient safety and KP's commitment to providing safe care. Moreover, member response to communication materials about patient safety issues was solicited, as well as response to proposed questions for Member Satisfaction surveys.