2005 Lawrence Transfer Award Winner

The Southern California Perinatal Patient Safety Project | to pdf >>

By Jean Sandoval, RN, MSN; Janice McDonald, RN, MBA; Suzanne Graham, RN, PhD

The Northern California Perinatal Patient Safety Project (PPSP) won the Lawrence Patient Safety New Project Award in 2004 (See "The Perinatal Patient Safety Project: New Can Be Great!" in The Permanente Journal 2005 Winter;9(1):25-7 and "Perinatal Patient Safety Project" in The Permanente Journal 2005 Spring;9(2):28-33). With the purpose to create high-reliability perinatal units through the use of human factors, techniques and systems improvements, the project borrowed from the United States Navy, NASA, and similar organizations that operate highly complex systems with few errors over long periods of time. Using the precepts of the "Four As of Adoption" (see "Practical Steps for Practice Transfer" in The Permanente Journal 2005 Fall;9(4):50-1), Southern California began implementation of PPSP in November 2003 at the Riverside Medical Center by administering the Safety Attitude Questionnaire (SAQ) to their Perinatal staff and physicians and initiated their PPSP Steering Committee to begin the planning process. The other nine Medical Centers began cyclical implementation in 2004.

The purpose of the Southern California PPSP was to: decrease human error and identify patient care systems in need of improvement; create a safe culture; develop a high-reliability perinatal unit; and apply a "Just Culture" environment to create a safe environment for team members. The project included training in team briefings/communication, assertion, error detection, and situational awareness to include identification of "red flags." A project tool kit was developed by the Southern California Regional PPSP project managers that described the core elements and was utilized by the medical centers during their start-up and throughout their planning meetings. This tool kit is now available from the National Risk Management Program Office (available at: http://kpnet.kp.org/qs/nrm/PPSP3/toolkit.htm) or the Southern California Project Managers. This project tool kit has been so successful, it is being requested by medical centers outside of Kaiser Permanente (KP).

Following a Leader

In 2003, Southern California Ob/Gyn Chiefs attended the PPSP conference in Northern California and returned enthused and excited to transfer and implement the program in Southern California. Southern California provides funds to each medical center to support innovation replication projects. PPSP used these funds to support staff attendance at the educational components of PPSP and at meetings for one full year. Being able to send champions to visit a medical center that had already successfully implemented the project was of integral value in easing the transfer process.

When Enthusiasm is a Drawback

Although the energy generated by the enthusiasm brought forth for implementing this project was essential and exciting, it also created some difficulties. Planning the transfer while the project was being implemented created some challenges that could have been avoided by fully developing the implementation plan prior to beginning the transfer; however, this might have been at the cost of some of the momentum, in which case transparent and open communication with a shared vision was vital.

Educational Components

The four educational components of the transfer included:

After completing the education components, staff and physicians almost unanimously felt CETT "brings it all together."

Conclusion

Implementing a regionwide program within the span of one year is a daunting task. Having committed Project Managers, regional support, and departmental enthusiasm makes the goal achievable and the challenge stimulating. Finally, the techniques utilized in PPSP are not exclusive to the perinatal unit. Other departments throughout Southern California are investigating the possibility of using this project as a model, specifically in the ICU and Medical/Surgical areas at Panorama City Medical Center and other departments at Orange County and Riverside Medical Centers.