Multifocal Clinical Performance Improvement Across 21 Hospitals.

Improving quality and safety across an entire healthcare system in multiple clinical areas within a short time frame is challenging. We describe our experience with improving inpatient quality and safety at Kaiser Permanente Northern California. The foundations of performance improvement are a "four-wheel drive" approach and a comprehensive driver diagram linking improvement goals to focal areas. By the end of 2011, substantial improvements occurred in hospital-acquired infections (central-line­associated bloodstream infections and Clostridium difficile infections); falls; hospital-acquired pressure ulcers; high-alert medication and surgical safety; sepsis care; critical care; and The Joint Commission core measures.

Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals.

A quality improvement initiative across 21 hospitals incorporated a multidisciplinary approach, breakthrough collaborative methods, evidence-based improvement methods and care guidelines, front-line rapid improvement cycles, consistent process-of-care documentation, and real-time incidence data. Statistically significant decreases in both all-stage and stages III, IV, and unstageable hospital-acquired pressure ulcers rates have been sustained for 5 years.

e-Measures: insight into the challenges and opportunities of automating publicly reported quality measures.

Using electronic health records (EHR) to automate publicly reported quality measures is receiving increasing attention and is one of the promises of EHR implementation. Kaiser Permanente has fully or partly automated six of 13 the joint commission measure sets. We describe our experience with automation and the resulting time savings: a reduction by approximately 50% of abstractor time required for one measure set alone (surgical care improvement project). However, our experience illustrates the gap between the current and desired states of automated public quality reporting, which has important implications for measure developers, accrediting entities, EHR vendors, public/private payers, and government.

Kaiser Permanente's performance improvement system, part 3: multisite improvements in care for patients with sepsis.

BACKGROUND: In 2008, Kaiser Permanente Northern California implemented an initiative to improve sepsis care. Early detection and expedited implementation of sepsis treatment bundles that include early goal-directed therapy (EGDT) for patients with severe sepsis were implemented. METHODS: In a top-down, bottom-up approach to performance improvement, teams at 21 medical centers independently decided how to implement treatment bundles, using a "playbook" developed by rapid cycle pilot testing at two sites and endorsed by a sepsis steering committee of regional and medical center clinical leaders. The playbook contained treatment algorithms, standardized order sets and flow charts, best practice alerts, and chart abstraction tools. Regional mentors and improvement advisers within the medical centers supported team-building and rapid implementation. Timely and actionable data allowed ongoing identification of improvement opportunities. A consistent approach to performance improvement propelled local rapid improvement cycles and joint problem solving across facilities. RESULTS: The number of sepsis diagnoses per 1,000 admissions increased from a baseline value of 35.7 in July 2009 to 119.4 in May 2011. The percent of admitted patients who have blood cultures drawn who also have a serum lactate level drawn increased from a baseline of 27% to 97% in May 2011. The percent of patients receiving EGDT who had a second and lower lactate level within six hours increased from 52% at baseline to 92% in May 2011. CONCLUSION: Twenty-one cross-functional frontline teams redesigned processes of care to provide regionally standardized, evidence-based treatment algorithms for sepsis, substantially increasing the identification and risk stratification of patients with suspected sepsis and the provision of a sepsis care bundle that included EGDT.

Implementation of a high-alert medication program.

INTRODUCTION: Greater than 500,000 doses of high-alert medications are administered throughout the Kaiser Permanente Northern California (KPNC) Program on an annual basis. High-alert medications (HAM) carry a higher risk of harm than other medications and errors in the administration of HAM can have catastrophic clinical outcomes. The purpose of this project is to ensure safe medication practices and to eliminate medication errors that cause harm to our patients.The Program: KPNC leadership, physicians, nurses, pharmacists, quality leaders, and labor unions worked with regional and local medication safety committees to: 1) standardize high-alert medication-handling practices; 2) enhance education programs related to medication practices, embedding these into annual core competencies of all staff who handle high-alert medications; 3) develop monitoring functions at both the regional and local levels to ensure sustainability and ongoing systems improvements. Begun in December 2005, this program covers the delivery of high-alert medications across the continuum of care and affects all patients receiving HAM. MEASURES: The initial phase of the monitoring process was put in place to measure compliance with implementation. Over the first few months of the program the 90% minimal threshold was surpassed with regional overall compliance of 95%. Following this initial process, the Regional Medication Safety Committee developed monitoring tools. Department managers carry out these concurrent observational audits at the medical centers with oversight by the Assistant Administrators for Quality and Service. These audits are designed to measure whether or not all medications on the HAM list are handled specifically to policy requirements, eg, independent double-checks, HAM stickers, etc. Audit specifications are provided for each audit tool. Medical Center audit results from the third quarter of 2006 through the third quarter of 2007 have shown a regional aggregate of 97.7% compliance. As the high percentages of compliance have held constant over time, more actionable metrics are being put in place for 2008.To determine whether or not the program is reducing HAM errors, data from the regional Quality and Risk database (MIDAS) related to all high-alert medication errors was reviewed. Two interventions were of note: in July of 2005, there was a renewed effort to educate leaders, managers, physicians, and staff on responsible reporting in a "just culture" and the introduction of the new Responsible Reporting Form. An increase in reporting was noted at this time. In December 2005, the HAM program was introduced. There is a statistically significant drop in errors reported for 23 consecutive months following this program. These findings were similar for all phases of the delivery process. A powerful indicator of improvement is the average days between major injury and death. As of November 30, 2007, it has been 232 days since the last significant negative event was reported due to a HAM. CONCLUSION: This program has been implemented in all of the KPNC Medical Centers and is in the process of being implemented in all KP regions. This spread has been endorsed by the Medical Directors Quality Committee and by the KP Boards of Directors. The Interregional Medication Safety Committee is overseeing the spread process. A toolkit containing all of the required tools plus additional materials and information has been developed and made available throughout KP. The program is the recipient of the 2007 Lawrence Patient Safety Award.

Histiocytes containing immunoglobulin crystals in the urine of a patient with IgA kappa plasmacytoma of the bladder.

Exfoliative cytology specimens from patients with plasma cell dyscrasias are rarely diagnostic, though there are reports of neoplastic plasma cells observed in pleural fluid and urine. Immunoglobulin concretions or crystals associated with neoplastic plasma cell populations have been well described. These crystals may be found within plasma cell nuclei or cytoplasm, extracellularly, or within cells of histiocytic lineage where they are presumably derived by phagocytosis. To the best of our knowledge, this is the first report of immunoglobulin crystals within histiocytes in the urine of a patient with plasmacytoma. A 61-year-old male underwent routine cystoscopy and urine collection to evaluate hematuria. The bladder biopsy demonstrated IgA kappa-producing plasmacytoma. Urine cytopsin preparations did not contain plasma cells, but there were histiocytic cells with degenerative nuclei and eccentrically located cytoplasmic spherical refractile hyaline crystals thought to be immunoglobulin crystals. This was supported by immunocytochemical staining.