1. P1P1 Kaiser Permanente Northern California: Set-up Phase Dr. Carmen Adams This presenter has nothing to disclose

2. Drivers of Quality and Safety The Quality Leader Goal Drivers Focus Areas Do No Harm Evidence Based Care Appropriate Care Setting & Managing Transitions Teamwork Safe Culture Prevent Infections Prevent Falls Prevent Pressure Ulcers Medication Safety Surgical Safety Perinatal Safety Critical Care Safety Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement Program Stroke Sepsis Maternal Child Health Quality Goals Advanced Illness Care Planning Care Transitions under development Appropriate Post-Hospital Care

3. #1 cause of hospital mortality 40+ % of all deaths #1 cause of hospital mortality 40+ % of all deaths At the Heart of Hospital Mortality… is the Germ

4. In Our Daily Practice We miss it We underestimate it We under treat it We cause it Find and name it Stratify risk Treat it reliably Prevent it

5. Building the Bridge for 21 Kaiser Permanente Medical Centers Mortality Diagnostic Spring 08 Sepsis Design Team Pilot Sepsis Summit Nov 08 21 Hospital Spread PrioritizeStandardize Process & Measures Create Vehicle for Change Implement

6. Critical Steps to Redesigning 2. Stratify Risk 2. Standardize 3. Create Vehicle for Change 4. Implement, Measure, Collaborate 1. Prioritize

7. Table Top Bedside Prove and Improve Create First Adopters and Advocates Gather and Test Implementation Tools: Playbook Build the Standard and the Measurement Strategy and Test Them Standardize SUMMIT

8. Blueprint for Change: A Common Framework All Patients with Infection are screened for

10. Teach and Test: Creating a Measurement Strategy Time of Dx 1 hour 2 hours 6 hours 6-12 hours Antibiotics Central Line MAP CVP ScvO 2 at Goal Lactate Clearance Do Not Delay for ICU Antibiotics Treat it reliably

11. Destination Constructing a Vehicle for Change Leadership alignment Standardization / Systemization Project Management Data that drives Compelling Story Vehicle for Change Ownership Uniformity Reliability Sustainability Compelling Case for Change

12. QUESTIONS?