The death of a 25-year-old man whose was given the wrong medicine via epidural triggered a drive to transform care and quality across the entire healthcare system of the American healthcare organisation Kaiser Permanente.
“The physician who administered the medicine was so devastated she never practised medicine again and the incident shook the region to its core.
“This kid should not have died and it was our failure that created his death,” Gregory A Adams, Executive Vice President, Group President and Regional President of Northern California, Kaiser Permanente told the Hospital Directions conference.
The incident led to the leadership of the organisation making a commitment that they were going to do whatever was possible to make sure that such an accident would never happen again.
Kaiser Permanente is an integrated managed care consortium, based in California, which serves 9.1m patient members across 8 states, 39 hospitals and employs 17,000 physicians and 49,000 nurses.
Through a system-wide leadership-led process they developed an evidence based approach to administering high risk medication. “Six months in to the new process we had 95% compliance and from 2006 to this day we have not had another death or major injury from a high risk medication. The incident made us realise that the system was willing to change and this was an opportunity to improve,” said Mr Adams.
Concern about soaring costs of healthcare in California where premiums had rocketed by 157% was another pressure for change and for cutting the costs.
“I realised there was great variation in quality and service and decided that we could tackle both the quality and the affordability agenda by doing the right thing for our patients. The message which we led with was that our aim was to provide the right care for the right patient at the right time in the right location with the right outcome,”csaid Mr Adams.
Leadership was aligned and people within the organisation were encouraged to think about how they could improve processes and their jobs. Data was really important for driving large scale, sustainable change and enabled everyone to stay focused on achieving the desired outcomes.
Four goals were identified: to improve the quality of leadership, give patients an exceptional experience, provide care without delay at the right time and ensure the workforce was skilled and motivated.
They also developed a sense of accountability. Mr Adams said one of the ways he did this was to bring various leaders into his office for three day meetings to work through what was working that should be maintained and what wasn’t working that had to be focused on and improved. Then they pulled in experts from around the region to design the best evidence-based practices that would achieve success. These were cascaded down the line to medical centres and everyone was trained on what needed improving.
Transparency in medical centres was improved with increased monitoring centrally of their performance and data.
“One of the things we were ruthless about was that processes should be the same across the organisation but at the same time we also created ways that allowed local teams to innovate,” said Mr Adams.
Multi-year goals, scorecards and a system-wide dashboard were created so that they could drill down into all the transformational initiatives and identify when thy turned from red (danger) to blue (improvement).
Alide Chase, Senior Vice President of Medicare Clinical Operations and Population Care, said a good deal of what they had learned about transformational change at Kaiser Permanente had been learned from the NHS.
“Our journey into quality was not one for the faint of heart. Many times we could have said we can’t do this but we had to keep going. Our notion was to keep going so that we could provide high quality healthcare for our population, a good experience for our families and improve the health of not only our patients but also of the communities we serve as well as being affordable,” she said.