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
Promising Methods for Improving Quality Through the Faster Spread of Best Practices
These abstracts reflect the critical importance of a forum for presenting promising quality efforts. Meetings focused on quality improvement, such as those hosted by the Institute for Healthcare Improvement, the American Medical Group Association, and many other organizations, represent a relatively small percentage of all scientific medical meetings. The publication of abstracts from a dedicated quality event such as the Kaiser Permanente National Quality Conference allows those inside and outside of Kaiser Permanente to learn about new and potentially unfamiliar practices that could improve care.
BEHAVIORAL HEALTH
The Impact of an Innovative Patient-Practitioner Therapeutic Community on the Management of Chronic Pain
Karen Peters, PhD; Barbara Gawehn, RN, LAc
Zero Suicide Implementation
Jacqueline Ryan, MPH; Pavan Somusetty, MD; Han Liang, MD; Eli Pahl, LCSW, CADC III;
Implementation and Dissemination of Cognitive Behavioral Therapy for Depression in Kaiser Permanente Hawaii: Impact and Lessons Learned
Bradley E Karlin, PhD, ABPP; Gregory K Brown, PhD; Shari Jager-Hyman, PhD; Kelly L Green, PhD; Michi Wong, PhD; Diane S Lee, LCSW, CSAC; Andrew Bertagnolli, PhD; Thekla Brumder Ross, PsyD
Lessons from Implementation of Behavioral Health Integration in Kaiser Permanente Washington
Rebecca Parrish, MSW; Ryan M Caldeiro, MD; Amy Lee, MPH
WELL BEING
100,000 Quitters and Counting—Striving for a Tobacco-Free Generation
Renee Fogelberg, MD; Mariko Muzzio, MPH; Annida Brunato; Karin Dove, MPH; Debora Sawyer, MD; Christopher Lee, MHSA
The POWER Journey of a Mid-Atlantic Permanente Medical Group Physician (Pursuit of Wellness, Engagement, and Resilience through Social Support)
Susan Leggett-Johnson, MD, MBA; Gene Gincherman, MD; Mary Zmuda, MPH
Malama Ola—Taking Care of Your Well-Being
Sharin Sakurai Burton, MD, PhD; Casey Akana, RN; Sandra Tompkins, RN; Kristy Yoshikawa; Julia Gregory, RN; Hyewon Jun, MD; Mae Lynne Swoboda, MPH; Courtney Farris, MA, MINTee; John Banagan, MPH, CHES; Eric Kamimura, DPT; Steve Nakata, COTA, MBA; Derek Chee, DPT; Quyen Nguyen, PhD; Jennifer Davis, RD; Kimberly Oshita, RD; Merle Miura-Akamine, MD; Kaipo Pau, MD; John Sheehan, MD
Increasing Team Safety and Response to the Threatening Member
Bradley Christie, PhD; Laura Ketterman, HEM
CARE MANAGEMENT
Continuing Care Quality Management: Practice, Performance, Proof
Peter Khang, MD, MPH, FAAFP; Jennifer Cortez; Christine Jordan, LCSW; Artem Aghourian, MBA
The Hepatitis C Care Cascade: Increasing Comprehensive Screening and Diagnosis
M Cabell Jonas, PhD; Michael Horberg, MD; Jacquelyn Redd, MD; Dana Sloane, MD; Eric Wollins, MD; Carla Rodriguez, PhD; Bernadette Loftus, MD
Measuring Diagnostic Error: A Review of Patient Complaints
Michael H Kanter, MD; Lawrence D Lurvey, MD; Kerry C Litman, MD; Ronald K Loo, MD; William Strull, MD; Mimi Hugh, MPH, MA; Maverick Au
No Place Like Home: Surgical Home Recovery
Michele Knox, MD; Wendy Rabinov, MD; Michael Nwynn, MD; Ashima Garg, MD, PhD; James Chang, MD; Claire Spanbock, MBA, RN, CNOR; Edgar Servais; Bijal Shah, MHSA; Tamar Fendel, MPH; Annie Davis, MPH; Joeffrey Hatton, MBA
Mid-Atlantic States Chronic Heart Failure Program
Farzaneh Sabi, MD; Machelle Behzadi, MHA; Betty Rice; Jessica Kane; Blair Van-Horn
Patient-Centered Management for Chronic Disease—A Model Applied to Parkinson Disease Care in Southern California
Jason Cheves, MSBA; Steve Cedrone, MBA; Todd Sachs, MD; Kathy Kigerl, RN, MN
Coordinated Regionwide Care Management Intervention for Patient with Chronic Obstructive Pulmonary Disease at Risk of Acute Exacerbation Reduces Hospital Days
Richard Mularski, MD, MSHS, MCR; Sanja Uskokovic, MS, PMP; David M Mosen, PhD; Bryan L Skalberg, MS; Achikam Haim, PhD; Marianne C Turley, PhD; Nancy L Lee, RPh; Wui-Leong Koh, MD
Decreasing Sleepless Nights for Patients and Practitioners by Fast Tracking Patients with Diagnostic Images Highly Suspicious for Cancer
Rischl Alindogan, BSN; Brian Doerning, MD; Robert Lin, MD; Jamie Difiori, MD; Harold Chow, MD; James Carter, RPA; Cynthia Payne, PhD
Combining Minimally Invasive Thoracic Surgery Techniques and a Multidisciplinary Care Model Leads to Superior Outcomes
Brian Timm, PA-C; Christopher Mutrie, MD; Piotr Starosta, PA-C; Julie Faulk, PA-C; German Collazo, PA-C; Yong Shin, MD; William Shely, MD; Thomas Lampros, MD; David Tse, MD
Patient-Centered Redesign of Total Joint Replacement Care: Achieving the Quadruple Aim
Kate Koplan MD, MPH, FACP, CPPS; Violeta Rabrenovich, MHA, CHIE
HIV/AIDS: A 30-Year History of Care Delivery
Patricia L Philbin, RN; Karen Lewis Smith, MHA; Susan McDonald, RN, MSN; Kathy Brown MD, FACP, AAHIVS; Dan Kent, PharmD
Enhancing Dispositions from the Emergency Department—the Northern California Journey to Care for Increasingly Complex Populations
Rayne Soriano PhD, RN; Vivian Reyes, MD; Jo-Ann Griffin, RN
Mid-Atlantic States Hospital Patient Day Rate Reduction
Farzaneh Sabi, MD; Pam Galley, MAOL; Claire Pagano, MHA; Blair Van-Horn
Preventing “Silent Droppers”: Standardizing Interventions to Prevent Lung Function Decline in Patients with Cystic Fibrosis
Jennifer Bass, MD; Adrienne Aldredge, MS; Ashley Addington; Richard Cohen, MD; Megan Danish; Susan Mikkelsen, MD; Kay Pasquesi; Kimberly Rondeau; Megan Wackford; Eric Walter, MD
EQUITY
Igniting an Inclusive Movement—Utilizing ILEaD (Inclusively Leading Through Equity and Diversity)
Laura Long, MBA; Susan Terrill
Addressing Disparities in Health with Motivational Interviewing
Deborah Baker, PhD; Hyewon Jun, MD, MPH; Dee Keyser; Peggy Latare, MD
The Community Action Poverty Simulation
Lakiesha C Tidwell; Madalynne Wilkes-Grundy, MD; Shari G Chevez, MD; Anna Khachikyan
MEDICATION MANAGEMENT
Reducing Opiate Use in Children and Teens: A Strategic Approach to a National Challenge
Anna Grosz, MD
Impact of Medication Reconciliation Programs on Reducing Readmission Rate and Enhancing Medication Safety During Transitions of Care
Alfonso Becerra, PharmD; Donald Yee, RPh; Karen Cham, PharmD; Sheireen Huang, PharmD; Shubhi Nagrani, PharmD; Adenola Akilo, PharmD; Karina Briones, PharmD; Kelvin Chan, PharmD; Carolyn Woo, PharmD; Chad Friday, RPh
PATIENT ENGAGEMENT
Human-Centered Design at Kaiser Permanente: A Creative Approach to Problem Solving
Jeff Hall; Connor Shea; Estee Neuwirth, PhD
Meeting Members’ Wishes in the Last Year of Life: A Journey Toward Concordance in Southern California
David Glass; PhD Michael Kanter, MD; Paul Minardi, MD; Susan Wang, MD
Using Insights from End-of-Life Care Survey to Drive Improvement of Care at the End of Life
Margaret C Wang, PhD, MPH; Diane Brown, PhD, RN, FNAHQ, FAAN; Peter S Khang, MD; Ruma Kumar, MD
Reducing Preventive Flips to Diagnostic—A Holistic Approach to Improving the Financial Experience for Members
Peter Gazanian; Erin Bilvado, MBA
TOTAL HEALTH
How Healthy Is My Community—Designing a Measurement System for Leaders and Implementers
Pamela M Schwartz, MPH; Elisa Wong, MPH; Allen D Cheadle, PhD; John M Vu, MPH
If You Want to Know How Mrs Smith is Doing, Ask Her! KP’s Improved Medicare Total Health/Social Risk Assessment
Tracy Lippard, MD, FACP; Carole Gardner, MD, AGSF; Matt Stiefel, MPA, MS; Ranu Pandey, MHA; Juliana Oronos, MPH
Bridging Barriers to Care Access and Delivery: The Automation of Nonemergent Transportation in Kaiser Permanente Mid-Atlantic States
Kyle M Heidenberger; Rachel E Hill; Melissa Baldwin, MS, MBA; Jason C McCarthy, PharmD, MBA
Addressing Social Needs: Organizational Learnings and Connecting with Our Communities
Sarita A Mohanty, MD, MPH, MBA; John F Steiner, MD, MPH; Nicole Friedman, MS; Briar Ertz-Berger, MD, MPH
TEAMS
The Kaiser Permanente Northwest Ventricular Assist Device Program
Barbara Amos, RN, MSN, CNS; Timothy Jacobson, MD; Yong Shin, MD; Ryan Morrissey, MD; Siobhan Gray, MD; Pamela Montes, RN, MSN; Allison Lipnick, LCSW
In-Basket Management: Empowering Nurses to be First Responders for Patient Messages, Providing The Right Care at The Right Time
Dones M Trojillo, MSN, RN; Maia M Patel, MD, ScM
The Implementation of High-Reliability Organization Model for the Environmental Services Department at Santa Clara Medical Center
Eric Williams, MHSA; Kari Frank, MS; Marc Smith, MHA
Building A Virtual Nursing Team: Implementation of the Advance Alert Monitor
Laure E Lisk, RN, MS, CPHQ, CPHRM; Elizabeth Scruth, RN, PhD, MPH, CCNS, CCRN, FCCM; Vanessa Martinez, MSN, MPH, RN; Bronwyn Cox, MSN, RN; Kris Wilson, RN, MSN, CPHQ
Improving Quality and Safety Together: Reducing Primary Cesareans Perinatal Core Measure Collaborative
Lyn Yasumura, MD; Cheri Lowre, MD; Leslie Casper, MD; Marianna Volodarskiy, RN, MSN, NE-BC
TECHNOLOGY
Leveraging Technology to Improve Appropriate Imaging Studies: There’s an App for That!
Peter Huynh, MD; Paymann Moin, MD; Michael Flores; Pamela Galvan; Steven Ethington
Using Human-Centered Design to Expand Telehealth Into the Hospital and Continuum
Reema Shah MPH; Estee Neuwirth, PhD; Lan Nguyen; Carissa Lim; George Go, MD; Tamara Hillstrom; Dan Huynh, MD; Margaret Pierce; Colette Lundahl; David Miura; Lisa Arellanes
Home Health Virtual Complexivist Physician Program: Leveraging Increased Scope of Care at a Crucial Time
Alicia Ahn, MD; Sandra Barton, MD; Binitha X Surendran, MBA, MS
Improving Patient Safety Via Information Transparency and Performance-Improvement Infrastructure
Asia Plahar, MS, RN; Kathy Ricossa, MS, RN
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