Kaiser Permanente Executive Summary

Kaiser Permanente’s Risk Management (RM) program was implemented to reduce adverse events, to learn from their experience, to improve their system, to reduce risks, to prevent injuries, and assist the health care providers in resolving conflicts. The Risk Management program is focused on constructing a substructure for a comprehensive and proactive risk management program (Kaiser Permanente, 2011). With executive and board level approval, Kaiser Permanente implemented the Enterprise Risk Management strategies in 2011 to improve patient safety and reduce adverse events. The Risk Management program reports to the chief strategic planning officer and provides senior management with the understanding of enterprise risk processes and how it is

managed. It ensures appropriate planning and focuses on major risks.
The Enterprise Risk Management structure has five components: risk control, risk assessment and profile, risk quantification, risk monitoring and reporting, and risk and control optimization (Jordan et al, 2013). The Risk Management program has specific objectives:
• To develop tools for early identification and reporting of adverse events that have or have the potential to cause injury, which may include using proactive risk assessments and continuing education based on needs that are identified through various tracking and reporting systems.

• To orientate new staff to their responsibility of providing a safe environment for patients and staff as well as proper reporting of incidents and future occurrence prevention.

• Incorporate data received from performance improvement activities as they are relevant to potential losses to the organization, staff, and patients. They make recommendations toward resolving issues which cause loss.

• Investigate, classify, and evaluate incidents, including complaints, to establish patterns or trends and to determine appropriate action to prevent a recurrence.

• Provide and coordinate education programs related to risk management issues and concerns. The topics branch from process issues identified by critical incident reviews, incident reports, and closed claims.

• Communicate their findings to appropriate departments and committees.

• Maintain a safe environment for patients and

staff.
• Comply with federal, state, and local regulatory requirements, and MDQR standards.
The Risk Management process has steps that must be followed, including risk identification and risk control. Risks are identified by utilizing different facets, such as proactive risk assessments, patient complaints, patient satisfaction surveys, chart reviews, and adverse event reports. The Risk Management program establishes and maintains a reporting system through the development and execution of systematic processes for detecting, reporting, gathering, analyzing, and summarizing incidents. Incidents must be reported within 24 hours of its occurrence or discovery of an incident to the Risk Management department via the incident reporting database, Peminic. Sentinel events must be reported immediately to the Director of Risk Management or the Clinical Risk Manager. Risk control provides education to staff on identified risk concerns and new standards and guidelines to maintain quality of care. It develops and reviews policies and procedures based on current guidelines and standards. Risk control also conducts case reviews with staff to develop action plans to improve processes. It helps to collaborate with operations and staff to ensure staff are trained on new equipment or implemented procedures. Risk control also implements recommendations by external review agencies related to risk management and patient safety.
Relevant findings discovered by risk management actions are reported to the Senior Quality Council as often as necessary, but at least annually. Examples of reporting include incident report summaries, claims and litigation summary reports by Claims Management, sentinel and never events, and variations from random screenings and adverse outcomes reported to the appropriate departments for quality improvement as they occur. Also equipment and device related incidents are reported in compliance with the Safe Medical Devices Act.
The Kaiser Permanente Risk Management plan is evaluated annually to determine its efficiency and to assure that problems that impacted patient care and safety were identified and resolved. The Risk Management plan is formally adopted by the Senior Quality Council (Kaiser Permanente, 2011).
Compare and critique the subject facility's Risk Management program to that of a model facility and whether the facility adheres to the recognized standard for risk management.
Kaiser Permanente has a responsibility for assisting in the delivery of effective and high quality of care keeping with professionally recognized standards.

Kaiser Permanente entrusts the responsibility for the implementation and oversight of the Risk Management program to the Director of Accreditation and Resource Stewardship and the Department of Performance Improvement and Patient Safety. The Risk Management committee provides a multidisciplinary environment for analysis of risk to in regards to patient safety on identified risk for the purposes of improving patient care, and reducing morbidity and death. It reviews reports on occurrences whether they have caused any harm to near misses to sentinel events. The information on identified risks are distributed as it is received to the Senior Quality Council, chairmen of clinical departments, and appropriate administrative staff. It prioritizes patient safety and forms teams to analyze processes and develop action plans for

improvement.
Hospital Corporation of America is another hospital organization similar to Kaiser Permanente. It has 162 hospitals, 112 surgery centers, and employs over 200,000 employees. It also utilizes the Enterprise Risk Management system for it Risk Management program which it implemented about 15 years ago (Jordan et al, 2013). It uses the following process for its Enterprise Risk Management process:

Reference: Jordan, B., Hughes, D., and Meehan, C. (2013). Enterprise Risk Management: Perceptions from Health Systems That Got It Right. Grant Thornton.

This is a similar process that is used by Kaiser Permanente in their Risk Management program.
Identify areas for improvement in the facility's Risk Management program, if any, and any recommendations you think should be implemented to lower risks in the facility.
Kaiser Permanente has developed a comprehensive Risk Management program. The only area of concern that I would foresee in the program is the multitude of individuals that are involved in the process. I understand that you need individuals with expertise in each area being evaluated, but I feel that it would be much easier to manage with less individuals involved in the evaluation. The team should comprise of individuals with the necessary expertise in the subject matter being evaluated. Some individuals would only need to be involved when it directly related to their expertise.