Back to Annual Meeting Page		American Public Health Association 133rd Annual Meeting & Exposition December 10-14, 2005 Philadelphia, PA

Abstract #103491

Karen Mazzocco, RN, JD¹, Julie Nunes, RN, MS, CPHRM², Sharon McFerran, RN, PhD, CPHQ³, Paul Preston, MD⁴, Michael Leonard, MD¹, Doug Bonacum¹, Kenneth T. Fong¹, and Nancy Corbett, RN, BSN³. (1) National Risk Management, Kaiser Permanente, 1 Kaiser Plaza, Oakland, CA 94612, 510-271-5719, karen.mazzocco@kp.org, (2) Northern California Region - Risk Management, Kaiser Permanente, 1950 Franklin Street, Oakland, CA 94612, (3) Northern California Region - Perinatal Patient Safety Project, Kaiser Permanente, 1950 Franklin Street, Oakland, CA 94612, (4) The Permanente Medical Group (TPMG), Kaiser Permanente, 2425 Geary Blvd., San Francisco, CA 94115

Birth Injury is now recognized as a rare but serious problem in obstetrical care. Communication, team culture, shift reports, sign outs and hand-offs lack of information and supervision issues have been identified as key recurring organizational system problems that have increased the likelihood of birth injuries at Kaiser Permanente. In an effort to improve the patient safety and quality of care, our interdisciplinary team adapted innovative approaches from the engineering realm to the perinatal care setting.

This session will present the development of an interdisciplinary and regional team effort to create a culture of safety in the perinatal care at Kaiser Permanente through the transfer of successful practices. It will also present the key approaches that lead to this culture of safety. The program, known as the Perinatal Patient Safety Project (PPSP), was first developed at Kaiser Permanente's Northern California region in 2002. The successful practices and approaches from the Northern California Region were recognized to be innovative and effective at reducing birth injuries and were subsequently transferred to other Kaiser Permanente Regions.

The key innovative practices that support the culture of safety at the Kaiser Permanente perinatal units comprise of four main areas: 1) High reliability perinatal unit assessment; 2) definition of fetal well being / electronic fetal heart monitoring (EFM) training; 3) Human factors / effective communication / pre-procedural briefings; and 4) rehearsing emergencies.

This session will present the evolution of these four approaches as they were disseminated to other regions at Kaiser Permanente and the implications and challenges for healthcare organizations.

Learning Objectives: At the end of the session,the participants will

• understand the process of a successful practice transfer in a large healthcare delivery system.
• understand the key practices that lead to better perinatal outcomes.

Keywords: Perinatal Outcomes, Quality of Care

Presenting author's disclosure statement:

I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.