In 2005, the Southern California Region had the honor of winning both the New and Transfer Projects Lawrence Patient Safety Awards: “Patient Safety Executive Walkarounds” won in the new project category; “Perinatal Patient Safety Project” won in the transfer category. These winning projects were honored at the annual Lawrence Patient Safety Award Recognition dinner on December 6, 2005. We are pleased to publish the Executive Walkarounds project and a brief overview of the previously published Perinatal Safety Project.
Walkarounds are a gloriously low-tech and relatively informal intervention encouraging staff to discuss safety concerns that might not otherwise get reported …
Patient Safety Executive Walkarounds (San Diego Area)
The Patient Safety Executive Walkarounds project demonstrate the value and importance of establishing direct communication between senior leaders and front-line health care workers. In 2000, the San Diego Medical Center volunteered as a pilot site for the Executive Walkarounds project. Leaders make announced visits to a department or unit to discuss issues that have or could have harmed patients. The Walkarounds create a climate of honesty and provide leaders with tools to show the importance of patient safety. Two-way communication develops through direct interaction between physicians and other involved health care workers; follow through resolves many issues that could affect patient safety. Currently, all Southern California Medical Centers conduct Walkarounds. The program is readily transferable to other Regions.
Walkarounds are a gloriously low-tech and relatively informal intervention encouraging staff to discuss safety concerns that might not otherwise get reported, and have these issues tracked.
Perinatal Patient Safety Project
The Transfer Award is given to a Region that best replicates a prior year's winner. Last year, Northern California won the Patient Safety Award for the Perinatal Patient Safety Project (PPSP) (see TPJ Winter and Spring 2005). By early 2006, The PPSP reached more than 2200 staff and physicians with human factors training and 1300 with Critical Events Team Training in all Southern California Kaiser Permanente Medical Centers. One of the purposes of the PPSP is to reduce birth injuries caused by human error and systemic problems by use of human factors skills. In 2003, Southern California OB chiefs attended a PPSP conference in Northern California, became fired with enthusiasm, and implemented a regionwide program. A briefer summary with anecdotal challenges and successes of transfer is printed in this issue.
The Lawrence Award
During 11 years as Chairman and CEO of Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, David M Lawrence, MD, challenged the entire health care industry to pursue patient safety as an integral component of high-quality care. When he retired, the Board of Directors established the Chairman's Patient Safety Awards to recognize and to honor projects that advance the quality of care by improving the safety of care. The goals are: 1) to create a culture of safety, 2) to develop and standardize successful patient safety measures in Kaiser Permanente facilities, and 3) to define and implement an innovative and transferable regional intervention in patient safety.
Eligibility specifications include this statement: “Projects nominated for the Chairman's Patient Safety Award should be evidence based or experience based, and address significant patient safety issues through substantial, measurable, and transferable changes that positively impact the provision of safe care. Processes or interventions developed through the project may represent innovations related to the patient as a partner in safe care, clinical practices, support systems, safety culture, health care team performance or the environment of care.” Criteria further specify a bias toward projects that demonstrate a change in outcomes, preference for projects involving members from various disciplines (Health Plan/Hospitals, Medical Group, and Labor), capability of replication interregionally, and bias toward practical, relevant and cost-effective solutions.
There is a call for abstracts in September of each year and Regions selected to submit full papers are announced during the December awards ceremony. Winners are selected by the Award Committee during a September meeting. Representatives from all Regions are invited to attend the annual Award dinner during the December meeting. Winners receive substantial recognition and publicity.
We applaud the many persons involved in these projects in Southern California.