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    Healthcare Plan Information

    Kaiser Permanente Mid-Atlantic States Patient Safety Initiatives

    Our Vision for Patient Safety at Kaiser Permanente

    The Kaiser Permanente Medical Care Program is committed to becoming the national leader in patient safety.

    Mission Statement

    As an integral part of the organization's Quality Program, patient safety requires providing care that is reliable, effective, and safe.  It is an ongoing and relentless commitment to build safer systems and prevent the preventable.

    Guiding Values

    • Providing quality care through sound business practices; making our best judgments and moving forward in this time of change; basing our decisions on consistent, agreed-upon values and goals; transferring learning from each situation.
    • Providing services by caring individuals so that the patients/members get what they need.
    • Doing the “right thing”; arriving at outcomes through a process marked by integrity, logical continuity, appropriate follow-up and closure; expecting professional integrity and personal commitment from our staff.
    • Promoting a trusting environment which supports delegation and empowerment as well as scrutiny of our own and others’ ideas and beliefs.
    • Ensuring that every patient has the right to care that is reliable, effective, and safe.  It is the responsibility of every leader, employee, and physician to continue to build safer systems to ensure patient safety. 

    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:

    • Engaging the patient as a partner in safety.
    • A strong and unified patient safety culture, with patient safety embraced as a shared organizational value.
    • A strategy that provides meaningful feedback on system performance and improvement activities.
    • A proactive performance improvement process that identifies and mitigates hazards, and redesigns systems and processes to improve reliability.
    • A prioritization process that optimizes the allocation of resources for patient safety performance improvement.
    • Ongoing identification, sharing, and implementation of best practices from other parts of the organization, other healthcare organizations, and organizations outside of healthcare
    • Ongoing patient safety training and education for individuals and teams and the use of simulation and experience-based learning to build sustainable performance.
    • Developing new knowledge and understanding of patient and workplace safety in the delivery system.

    Strategic Themes

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

    Core Theme Description
    Safe Culture Create and maintain a strong, unified patient safety culture at Kaiser Permanente, with patient safety embraced as shared organizational values and acknowledged pre-requisites of "quality you can trust."
    Safe Care Ensure the actual and potential hazards associated with high risk procedures, processes, and patient care populations are identified, assessed, and controlled in a way that demonstrates continuous improvement and excellence in care.
    Safe Staff Ensure staff possesses the knowledge and competence to safely perform required duties and improve system safety performance – this includes a goal of eliminating occupational injuries/illnesses to staff.
    Safe Support Systems Identify, implement, and maintain support systems that provide the right information, to the right people, at the right time.  This includes knowledge sharing networks and learning through simulation.
    Safe Place Design, construct, operate, and maintain a safe environment of care as well as evaluate, purchase, and utilize equipment and products in a way that promotes the efficiency and effectiveness with which safe healthcare is provided.
    Safe Patients Engage the patient and their family in improving overall system safety performance, actively participating in their own safe care and maintaining trust and respect.

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

    1. An understanding of human performance and human factors;
    2. The creation and maintenance of a psychologically safe learning culture; and,
    3. The application of both simulation team training and safety science to continually improve safe practice.

    Other patient safety initiatives:

    • Surgical Safety Briefing: All ambulatory surgery centers (ASCs) in the Kaiser Permanente Mid-Atlantic States Region have a standardized, comprehensive interprofessional briefing checklist with participation from all operating team members.  It is a three phase process that occurs prior to induction of anesthesia, prior to the start of surgery, and prior to leaving the operating theater.  Along with side, site, and patient verification, a review of all equipment, implants, and any patient concerns are discussed.  Our briefing is patterned after the World Health Organization Surgical Checklist and includes all elements applicable to an ASC setting and all elements required by The Joint Commission (TJC).
    • Outpatient Procedural Safety Briefing:  Following the same process as our Surgical Safety Briefing, there is a team briefing for all procedures performed in our Outpatient Procedure Suites.  The safety briefing is inclusive of the three phases: prior to procedural sedation, prior to the start of procedure, and prior to leaving the procedural suite.
    • Universal Protocol Checklist is a standardized process used for any invasive procedure performed in our medical office environments. Patient, side, site, and procedure are verified with patient and any team members that may be assisting the practitioner for the procedure.  Patient allergies, and applicable test result expectations are also discussed during the UP discussion.  All elements expected from TJC are included in this checklist.
    • Patient Safety Research: current research in use of simulation to: discover latent conditions in new facilities and clinical services, test procedures, equipment and workflows, train teams with skill reinforcement, developing critical pathway checklists and decision aids.
    • Performance Improvement methodology to enhance workplace and patient safety.  Working through Unit Based Teams to collaborate on efforts that refine best practice ideas that consider solutions to deliver safe care for both our employees and our members that we care for.
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