Federal Employee Health Benefits

Kaiser Permanente Northwest
Patient Safety Initiative

Patient safety, the freedom from unnecessary risk or harm associated with health care, is an integral component of Kaiser Permanente's philosophy to provide quality health care our members can trust. Kaiser Permanente Northwest (KPNW) incorporates patient safety into the every day workings of the organization, guided by three principles:

• Patient Safety comes first.
• Patient Safety is every patient's right.
• Patient Safety is every individual's responsibility.

Kaiser Permanente's model of care has long encompassed proactive patient safety features. At Kaiser Permanente, physicians practice Permanente medicine - to share decision making with patients, to follow guidelines for care that are based on clinical evidence (which are accessible to all clinicians on our intranet website and supported by

prompts in our electronic medical record), and to work closely with other health care practitioners. In our unique integrated care delivery system, physicians and specialists work alongside other health care professionals to care for our members and can easily share best clinical practices, diagnoses, and other patient information.

KPNW established the multi-disciplinary Patient Safety Oversight Committee (PSOC) in 1999 to improve patient outcomes and the health care quality process by concentrating on identification and prevention of health care errors that might cause patient harm. In 2002, KPNW developed a Patient Safety Coordinator position within the Quality Management department to further support the region's patient safety activities. In addition, PSOC has charged 3 subcommittees and a variety of workgroups to focus on specific error reduction and patient safety improvement projects, including medication safety. Both the inpatient and outpatient pharmacy departments have each added a Clinical Quality Coordinator position that is dedicated to medication safety.

Medication safety improvements include the installation of a bar coding system to verify correct medication dispensed to the patient, changes to prevent mix-ups from look-alike and sound-alike drugs, and the development of prescribing reminders or "alerts" in our automated medical record to prevent high-risk drug interactions. Pharmacy staff regularly performs self-assessment audits of clinic modules/pharmacies to review and improve medication storage and handling and then share their learnings with nursing staff. KPNW also has a monthly pharmacy newsletter that is sent to all pharmacy staff that shares information and tools to reduce medication errors. Our commitment to medication safety includes providing pharmacy staff both electronic tools and information to help them prevent errors before they happen. If a medication error does occur it is reviewed by the Pharmacy Quality Coordinator who looks for system issues that may have contributed to the error. When potential system problems are identified, they are taken to the appropriate Medication Safety Committee to develop, implement and monitor a plan of action. Trends and systems issues are then brought back to the PSOC for further review and follow-up. PSOC regularly assesses regional patient safety activities and then prioritizes future opportunities into the annual planning process.

KPNW is committed to the education and training of staff in the area of patient safety. Both physicians and staff receive patient safety education in various new employee orientations and PSOC sponsors additional employee patient safety training on a regular basis. In 2002, over 80% 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 walk-rounds have been implemented at Kaiser Sunnyside Medical Center for the purpose of expressing leadership support for patient safety as well as soliciting patient safety concerns from staff and physicians. A staff/physician patient safety Newsletter was inaugurated in 2002 to share patient safety information throughout the organization. KPNW also has a patient safety website for employees to access a variety of patient safety tools and information.

Patient safety information is also regularly shared with physicians. We provide individual clinical indicator profiles to physicians including performance on prevention and disease management programs. Patient safety information including system changes are shared at quarterly quality department meetings. There is a region wide METRO quality and systems program that feeds back information to quality clinicians about problems and solutions around the region. Risk management and closed claim data involving specific patient safety issues are fed back to chiefs and departments on an annual or biannual basis. Physician performance and care given to our members are reviewed by physician peer groups and other internal committees.

At KPNW, physician recognition is achieved in a variety of ways. The Annual Distinguished Physician Award allows physicians across the region to give input on physicians' practice related to quality, service and peer interactions. All individuals whose names are submitted are recognized and 5 physicians are chosen to receive both a plaque and a monetary award. At the Credentials Committee (a peer review committee), physicians who have outstanding quality and service reports (from both members and staff) receive a note from the committee chairs recognizing their achievement. Clinicians are also recognized in weekly email communications to all staff across the region. An Annual Quality Chiefs and Representatives meeting also recognizes and shares the learnings and good works from our physician quality leaders.

A significant step in enhancing patient safety that is identified broadly throughout health care is the creation of an environment in which health care workers are encouraged and feel comfortable in identifying and reporting those things that have or could lead to errors in patient care. Reporting of close calls in particular (errors that were caught prior to patient harm) is embraced as an opportunity to build safer systems. In 2000, Kaiser Permanente and 60,000 employees in an AFL-CIO coalition joined forces as part of the National Labor Management Partnership Agreement to promote patient safety. From this partnership emerged a commitment to improve patient safety through reporting of actual errors and close calls. Kaiser Permanente began working in 2001 to develop the framework and implementation process for responsible reporting throughout the organization.

KPNW has long had reporting mechanisms in place that identify both adverse outcomes and potentially harmful situations. In 2003 and 2004, KPNW is focused on implementing an improved computerized error and close call reporting system available to all staff to further encourage reporting. One of the top regional priorities has been to increase the number of close call reports to underscore the importance of a patient safety culture and to surface potential problems for proactive solutions. We are also developing non-punitive error reporting policies and manager/employee education, including appropriate feedback with staff, so that employees feel they can report errors without fear of retribution. Reported information is used to identify system-based causes of errors, and to make improvements to systems of care with the goal of reducing the likelihood of future errors that could cause patient harm.

Involving patients in their own care and creating member awareness continues to be an integral part of our patient safety agenda. Patient Safety information for KP members is available on KP's Internet site, and in member guidebooks, newsletters and brochures. Patient partnership materials have been developed to further empower patients and encourage their active participation in safe outcomes. In 2002, focus groups were conducted in order to gain an understanding of how members view patient safety and KPNW's commitment to providing safe care. Members were also asked to respond to communication materials about patient safety issues, as well as to proposed questions for future Member Satisfaction surveys.