Over the past five years, Kaiser Permanente Chairman and CEO George Halvorson, who will retire at the end of this year, sent a weekly letter to the 180,000 people who work for the nation's largest integrated healthcare delivery system. Every letter celebrated a particular success within the organization. The letters usually focused on care delivery. They have now been compiled in a book,
KP Inside: 101 letters to the people of Kaiser Permanente. Here are excerpts from three:Celebrating our sepsis mortality reduction successesNov. 18, 2011
Dear KP colleagues,
Sepsis is actually the No. 1 cause of death in hospitals in California.
According to the official state death-rate statistics, more people die in hospitals from sepsis than die from cancer, stroke or heart disease.
State statistics tell us that 24% of seniors who die in California hospitals—nearly one in four seniors—die from sepsis.
Very few people know that to be true. Very few people are doing anything about it.
Our goal is to have the safest hospitals in America, so we are an exception to that rule. We are doing something about sepsis—and what we are doing is working.
When we started measuring the percentage of our sepsis patients who did not survive, our first mortality numbers were significantly more than 20%. One in four sepsis patients did not survive.
Now we have made consistent improvements in every hospital and our death rate has dropped to 11%.
That is half as many people passing on. How did we save all of those lives?
We had very smart people focus on the problem to figure out what we needed to do to make care better for sepsis patients.
It turns out that speed is essential. There is a time called the “golden hour” at the beginning of treatment for each patient where rapid intervention with the right treatment really is golden.
Delayed care can be fatal. Fast care can work miracles.
So we figured out how to diagnose quickly, pre-plan every response, predefine the right medications and train people in our care sites to respond in a hurry with the right stuff in the right way.
We did not surrender to sepsis. We did not say—“Sepsis happens and that's too bad.”
Instead, we said—“Sepsis happens—let's save a lot of lives by responding really, really well to provide the right care to every patient.”
That's the right answer.
So my letter this week celebrates the brilliant teams of KP folks who figured out how to save all of those lives—and all of the caregiver teams who are getting better at saving lives every day.
Continuous improvement is a wonderful thing.
Celebrating our pressure ulcer prevention program
Dec. 17, 2010
Dear KP colleagues,
Pressure ulcers can eat through the skin and muscle of a patient and create a wound that is all the way to the bone.
Pressure ulcers can disfigure patients, sometimes forever. After ulcers heal, plastic surgeons often have to repair the damage caused by the ulcer in its destructive stages.
Pressure ulcers can kill—and it can be a very painful way to die.
Pressure ulcers have been a major curse of hospital caregivers for as long as hospitals have existed. Every hospital has its truly sad stories about patients whose lives were ruined and ended by pressure ulcers.
Why am I writing about pressure ulcers and the misery they cause in my weekly letter?
We recently had our annual Dr. David Lawrence Patient Safety Award ceremony (named for the former CEO of Kaiser Foundation Health Plan and Hospitals). Every year, we celebrate a region that has done an exceptional job on patient safety.
This year's winner was Northern California, for putting in place a pressure ulcer prevention program so effective that two of our hospitals went two full years without a single reportable Stage 3 or greater pressure ulcer.
Zero is an amazing number.
Zero takes an incredible consistency of caring for each patient. Zero is the result of care so good it deserves to be called deeply compassionate care—treating each patient like family—taking the patients' best interests so much to heart that every single patient gets the care they need to make sure those ulcers don't happen.
Preventing pressure ulcers is a wonderful thing to do. The patients who never get a Stage 3 or higher ulcer don't know how extremely lucky they are to be getting their care from us—because we care enough to make sure those ulcers don't happen.
Congratulations. Well done.
Celebrating the 2011 David Lawrence Patient Safety Awards
Jan. 6, 2012
Dear KP colleagues,
One program cut the number of pressure ulcers in a hospital to zero for nearly a year.
Another program cut the number of medication errors by more than half.
Another program helped high-risk patients in times of transitions from care site to care site.
Another program reduced the increase, abuse and risk of OxyContin use.
Yet another program created rapid-response teams that achieved a 47% reduction in patients needing “code” level of care.
Another program set up extensive training programs using mannequins and computerized patients to improve team care and patient response techniques and approaches.
Another program decreased therapeutic misuse of acetaminophen.
What do all of those programs have
They are all Kaiser Permanente programs that have been nominated for the Dr. David Lawrence Patient Safety Award.
My letter this week celebrates the Kaiser Permanente patient-safety programs that were so distinctive and well done that they earned Lawrence Award recognition.
George Halvorson is Chairman and CEO of Kaiser Permanente