Improving Patient Safety Via Information Transparency and Performance-Improvement Infrastructure
Asia Plahar, MS, RN; Kathy Ricossa, MS, RN
https://doi.org/10.7812/TPP/19-039-44
Abstracts from the Kaiser Permanente 2019 National Quality Conference
From Northern California
Background: The Kaiser Permanente Santa Clara Medical Center created a performance-improvement infrastructure focusing on total harm reduction, which is a composite of the following measures: Central line-associated blood stream infection, hospital-acquired pneumonia, catheter-associated urinary tract infection, Clostridium difficile, falls, hospital-acquired pressure injury, and safety events. A transformational shift began in March 2016 when an infrastructure was created as a strategic plan to address total harm using a multidisciplinary team collaboration, evidence-based best practices, and performance-improvement methodology. In July 2017, this project of creating a data transparency system for total harm outcome and process measures was implemented.
Methods: The Total Harm Scorecard is composed of patient safety outcome and process measures. Outcome data are updated in real time and process-measures data are collected via rounding on patients daily. Outcome and process-measure data are visible through scorecards and control charts for medical center and departments. The Total Harm Scorecard is reviewed daily at the patient progression hub and managers report harm-reduction strategies in real time. The Total Harm Scorecard link is accessible to the entire medical center. The Total Harm Scorecard and department-level action plans are presented to the medical center’s Quality Oversight Committees, which report to the Medical Executive Committee.
Results: In 2017, the Kaiser Permanente Santa Clara Medical Center achieved a 30% reduction in patient total harm, an 8.8% reduction in the rate of patients acquiring a nosocomial infection; 78 patients’ lives were protected, 729 hospital days were avoided, and there was $1,526,928 in savings.
Discussion: The performance-improvement infrastructure and total harm data visibility has improved the safety of our patients and protected 78 patients from harm in 2017 at our medical center. The performance-improvement infrastructure and total harm data visibility system was created as a strategic plan to reduce patient harm. As the result, 78 patients’ lives were protected and harm was reduced by 30% in 2017. This total harm reduction transformational model can be generalized to other health care systems nationally and internationally.
Abstracts from the Kaiser Permanente 2019 National Quality Conference
