Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values.

Rationale: Treatments for patients with sepsis with intermediate lactate values (≥2 and <4 mmol/L) are poorly defined.

Objectives: To evaluate multicenter implementation of a treatment bundle (including timed intervals for antibiotics, repeat lactate testing, and intravenous fluids) for hemodynamically stable patients with sepsis and intermediate lactate values in the emergency department.

Methods: We evaluated patients in annual intervals before and after bundle implementation in March 2013.

Evaluation Following Staggered Implementation of the "Rethinking Critical Care" ICU Care Bundle in a Multicenter Community Setting.

Objectives: To evaluate process metrics and outcomes after implementation of the "Rethinking Critical Care" ICU care bundle in a community setting.

Design: Retrospective interrupted time-series analysis.

Setting: Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system.

Multifocal Clinical Performance Improvement Across 21 Hospitals.

Improving quality and safety across an entire healthcare system in multiple clinical areas within a short time frame is challenging. We describe our experience with improving inpatient quality and safety at Kaiser Permanente Northern California. The foundations of performance improvement are a “four-wheel drive” approach and a comprehensive driver diagram linking improvement goals to focal areas.

Fluid volume, lactate values, and mortality in sepsis patients with intermediate lactate values.

Rationale: Patients with severe sepsis without shock or tissue hypoperfusion face substantial mortality; however, treatment guidelines are lacking.

Objectives: To evaluate the association between intravenous fluid resuscitation, lactate clearance, and mortality in patients with "intermediate" lactate values of 2 mmol/L or greater and less than 4 mmol/L.

Measurements And Main Results: This was a retrospective study of 9,190 patients with sepsis with intermediate lactate values.

e-Measures: insight into the challenges and opportunities of automating publicly reported quality measures.

Using electronic health records (EHR) to automate publicly reported quality measures is receiving increasing attention and is one of the promises of EHR implementation. Kaiser Permanente has fully or partly automated six of 13 the joint commission measure sets. We describe our experience with automation and the resulting time savings: a reduction by approximately 50% of abstractor time required for one measure set alone (surgical care improvement project).

Kaiser Permanente's performance improvement system, part 3: multisite improvements in care for patients with sepsis.

Background: In 2008, Kaiser Permanente Northern California implemented an initiative to improve sepsis care. Early detection and expedited implementation of sepsis treatment bundles that include early goal-directed therapy (EGDT) for patients with severe sepsis were implemented.

Methods: In a top-down, bottom-up approach to performance improvement, teams at 21 medical centers independently decided how to implement treatment bundles, using a "playbook" developed by rapid cycle pilot testing at two sites and endorsed by a sepsis steering committee of regional and medical center clinical leaders.

The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators.

Objective: To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California.

Design: Longitudinal analysis.

Setting: 35 medical facilities of Kaiser Permanente Northern California, 1997-2007.