1. November 12, 2012 Diagnostic Errors in Medicine William Strull, MD Medical Director Quality and Patient Safety The Permanente Federation, LLC Prepared by: Bettygene Egan, MBA

2. 2 Kaiser Permanente Regions

3. Coded Closed Claims 3 Claims DistributionsPayout Distributions Diagnosis

4. High-Level Categories 4  Cognition  Visual diagnosis  Closing the loop/Follow-up

5. Staff Engagement and Learning 5  Communication down to the front line level  Diagnostic Reliability and Improvement Initiative Team and Committees (DRII)  Risk Managers Operations Team  Sentinel Event Risk Care Integration Team

6. Analyze, Share, Prevent, Inter-REgionally, 6

7. Specimen Handling & Tracking  Anatomical Specimen Handling  Inter-Regional Specimen Tracking 7

8. 8 Specimen Handling Anatomical Pathology Specimen Handling Project Colorado Region

9. Background Strategic Alignment Strategic KP Imperatives Transform Care Delivery Solving for Affordability Lack of a uniform specimen tracking mechanism throughout Kaiser Permanente has lead to lost or misplaced specimens during transit or while being processed at hospital or regional laboratories. Existing Specimen Tracking capabilities do not support all specimen tracking needs for Kaiser Permanente’s multi-site intra-regional laboratories. Some of the identified specimen tracking pain points during specimen transport includes: specimens lost, misplaced, misrouted, relabeled and stored at the incorrect temperature resulting in unusable specimens. Then they must be recollected when possible resulting in missed or delayed diagnosis, and even litigation risks when high value specimens are lost or mishandled. The consequence of a loss depends on the type of specimen, varying from the irreparable impact of a lost diagnostic specimen that can’t be recollected to the inconvenience a member experiences being recalled for a repeat blood collection. Ultimately, these lost specimens results in decreased member and provider satisfaction, increased costs due to repeated procedures or even worse, litigation. CD Bio National Strategy 9 Benefits Realization Continuous Improvement Productivity Gains Compliance Requirements Cost of Doing Business Member Satisfaction

10. Identify and Manage 10 Outpatient Safety Nets that proactively identify and manage patients with an outpatient safety risks

11. Categories of Gaps 11  Necessary Follow-up Care Tracking/follow-up of abnormal results  Medication Management Appropriate monitoring for long-term medications  Diagnosis Detection Identify potentially undiagnosed cases  Potentially Harmful Interactions Pharmacist recommends alternative drug therapy

12. Patient Safety Measurement Portfolio 12 % of breast cancer diagnosed at stage 1 or 2 % of cervical cancer diagnosed at stage 1 or 2 % of colorectal cancer diagnosed at stage 1 or 2 Testing for HIV among HIV uninfected members diagnosed with sexually transmitted infection

13. 13  The After Visit Summary Improves patient follow through with the completion of diagnostic tests Engages the patient as “partner” Is the #1 member satisfier  Overdue Results Notification Provides a safety net to ensure that tests are completed  “Tickler” Reminder Messaging Allows clinicians to send themselves a reminder to make sure an urgent or important diagnostic test, referral or “hand off” has been completed  In Basket Monitoring Ensures that all in basket messages, with abnormal results, have been addressed in a timely manner KP HealthConnect

14. 14 Engagement  Patient Family Centered Care  SMART Partners

15. Diagnosis and Engagement 15

16. Diagnosis and Engagement 16

17. Questions 17