Ohio Safety Action Teams


2008 Lawrence Patient Safety Award


Spring 2009 - Volume 13 Number 2



Ambulatory care presents many challenges for implementing a risk management and patient safety program. In addressing a perceived problem about inadequate response to reports in the Kaiser Permanente Ohio Region, interdepartmental Safety Action Teams (SATs) were created and activated in 2005-6.

The Kaiser Permanente (KP) Ohio Region includes various locations widely separated through northeast Ohio. Team Lead Registered Nurses, Managers, and Directors are responsible for primary care, specialty care, and other services that are located across the Region rather than in one building. Physicians and allied health professionals practice in more than one location. Practice variations in affiliated hospitals with which the Ohio Permanente Medical Group (OPMG) contracts—only some of which have OPMG Hospitalists—add to the challenges.

To improve the process, the SATs mapped the current process and ran Plan-Do-Study-Act cycles to test the new process prior to implementation. Nineteen SATs have been implemented since inception and eleven are completed. In a post-SAT survey, participants showed they knew more about building a reliable process, their job satisfaction increased, patient safety was improved, and the gains were sustained. The plan to continue SATs is felt to have a solid future and is readily transferable to other areas and facilities.


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