Patient Safety Executive Walkarounds

Excerpt

Since the release of the IOM report To Err Is Human in 1999, significant progress has been made in patient safety. One of the remaining challenges is the need to continually improve the culture of safety. This is a long-term proposition, and one that must be driven foremost by our leaders. In a consensus statement from the National Quality Forum, Dr. Kenneth Kizer pointed out, “There simply is nothing more important in overseeing a hospital or other health care facility than ensuring it is as safe as possible for patients.” Improving patient safety should be among the highest priorities of health care leaders and managers. To lead patient safety improvements, executives must be visible and must take an active role in patient safety. To this end, Kaiser Permanente has designed and implemented Patient Safety Executive Walkarounds as a tool for leaders to (1) visibly demonstrate patient safety as a high organizational priority, and (2) learn from direct care staff and physicians about near misses, errors, and hazards that jeopardize patient safety. This paper will discuss our experience with Patient Safety Executive Walkarounds, including:

1. Program design.

2. Tool development.

3. Outcome metrics.

4. Leaders, manager and staff education.

5. Analysis and categorization of information received.

6. Key success factors.

7. Outcomes and improvements to date.