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Julie ApoldSr. Director of Patient SafetyMinnesota Hospital Association

Laying a “SAFE”

Foundation

MHA Calls-to-ActionBrief History

AHE Law went into effect July 2003 Report any of the 28 National Quality Forum

Serious Reportable Events Event types with highest # of reports:• Wrong Body Part Surgery• Retained Foreign Objects• Falls• Pressure Ulcers

Focused Approach to Improvement

Focus on top events• Determine best practices• Implement best practices

Convened advisory groups• Reviewed national and local best practices• Reviewed AHE data• Developed implementation best practices

Patient Safety Road Maps

MHA Statewide Calls-to-Action

Road Map Structure

SAFE Topic-specific Gap Analyses

“SAFE”

SAFE = S (Safety Teams/Org Structure)

Action 1: Secure endorsements and resources for XX Prevention Program

• Leadership:o Endorses the worko Clearly communicates goalso Regularly reviews progress toward goalso Supports adding resources as appropriateo Designates a senior leadership sponsor

SAFE = S (Safety Teams/Org Structure)

Action 2: Promote XX prevention representation/champions/liaisons throughout the facility• Regular Interdisciplinary team• Champions• Liaisons• Ad-hoc for specific projects• Designated coordinator(s)

o With designated time!

SAFE = S (Safety Teams/Org Structure)

Action 3: Identify gaps and develop action plans

• The interdisciplinary team:o Reviews and updates the XX prevention programo Reviews data results at least quarterly and identifies

strengths and opportunitieso Develops a plan to prioritize and address improvement

opportunitieso Commissions subgroups as needed

SAFE = A (Access to Information)

Action 1: Track progress on process and outcome measures• Observational audits• Inter-rater reliability• Capture adverse event details

SAFE = A (Access to Information)

Action 2: Review and analyze data for improvement opportunities• Routinely review and analyze data• Track progress against established targets

o Run charts, control charts, dashboards, scorecards

• Prioritize and act upon identified issues

SAFE = A (Access to Information)

Action 3: Data is shared on a regular basis to promote system-wide learning and transparency• Share vertically and horizontally• A story with worth 1,000 data points

SAFE = F (Facility Expectations)

Action 1: Leadership establishes and communicates clear expectations• All staff informed of expectations• Culture supports speaking up/stopping the line• The “stop the line” process clearly outlines:

o When to stop the lineo How to stop the line (verbal/non-verbal cue)o The chain of command to follow if not supported in

stopping the lineo Clear communication to staff from managers and

leadership that staff will be supported if they speak up

SAFE = F (Facility Expectations)

Action 2: Education for staff and physicians• Orientation • Annually

SAFE = F (Facility Expectations)

Action 3: Establish a structured communication process • Structured communication tools, e.g., Situation,

Background, Assessment, Recommendation (SBAR); isolation signage

• A structured hand-off process (what should be communicated; how?)o During shift changeo Between departments/unitso To other facilities

SAFE = F (Facility Expectations)

Action 4: Disclose unanticipated events• Promptly inform patients/families when an

unanticipated event occurs• Establish who should discuss with

the patient/family and how• Provide training and support to staff

on effective disclosure strategies• Keep patient/family updated

SAFE = E (Engagement of Pts/Families)

Action 1: Educate and empower patient/ families• Address any barriers to patient/family

understanding their role in HAI prevention o Cultural, language, hearing impairment, health literacy

• Educated on their role and what they can expect to see from caregivers

• Assess patient/families’ level of understanding e.g., teach back

• Encourage “speaking up”

The MAPS Journey to

Developing the Culture

Road Map

Timeline of Culture Initiative

Late 2009 Operations Committee commissioned Culture Exploratory Work Group

MAPS Topic Criteria: Topic expands across multiple health care settings Topic success requires collaboration among a multi-stakeholder work group Work on the topic will have an impact on the safety and quality of care in MN Organizations are willing and able to participate in and carry out the necessary work.

Exploratory Work group members:

Julie Apold and Tania Daniels MHA Steve Meisel, Fairview Health Services

Diane Rydrych, MDH Cally Vinz, Gary Oftedahl, ICSI

Marie Dotseth, Dotseth Consulting Susan Peterson, Anoka Metro Regional Treatment Center

Jennifer Lundblad, Kelly O’Neill, and Denise White, Stratis Health

Rob Welsch, VHA Upper Midwest

Becky Schierman, MMA

Timeline of Culture Initiative

2010 – Exploratory Work GroupTook into consideration current Culture work in Minnesota:• VHA/AHRQ findings and gaps• Stratis Health findings and gaps • ICSI findings and gaps

Identified project/focus• Identified three phases of addressing culture:

o Data collection (Initial Phase)o Data analysis/interpretation: identifying the gaps (Planning Phase)o Implementation work to address gaps (Action Phase)

Discussed existing data• Survey tools: AHRQ, VHA, ICSI, HLCAT

Identified list of attributes for a safety culture

2010 – Exploratory Work Group Recommendations There is a role for MAPS to address a culture of safety that expands across health care settingsProvide a framework of best practices, implementation support, and measurementDevelop best practices road map and guide health care providers who are embedding a culture of safety within in their organizationsCreate a community standard through a statewide call-to-action across all settings of care

2010 MAPS Governance DecisionsJuly 14th MAPS Steering Committee approved• MAPS moving forward with Culture Roadmap and budgeting for

a project manager

Timeline of Culture Initiative

MAPS Patient Safety Culture Workgroup

Co-Chair: Nancy Kielhofner, Allina Hospitals & Clinics

Co-Chair: Kate Peterson, Stratis Health Julie Apold, Minnesota Hospital

Association Karyn Baum, University of MN Sandy Berreth, MNASCA representative Shirley Brekken, MN Board of Nursing Tania Daniels, Minnesota Hospital

Association Stan Davis, Fairview Health System Marie Dotseth, Dotseth Consulting Ruth Edwards, MN Council of Health Plans

representative Kris Ehlers, Fairview Health System Marilyn Grafstrom, LifeCare Medical

Center Karen MacDonald, MOLN representative

Ruth Martinez, Minnesota Board of Medical Practice

Christine Milbranth, Metro State University Christine Norton, Minnesota Breast Cancer

Coalition Gary Oftedahl, ICSI Nancy Page, Orthopaedic Institute Surgery

Center Susan Peterson, Anoka Metro Regional

Treatment Center Diane Rydrych, Minnesota Department of

Health Becky Schierman, Minnesota Medical

Association Liz Sether, Aging Services of Minnesota Cally Vinz, ICSI Rob Welch, MD, VHA Upper Midwest Linda Zespy, Project Manager

Goal: 1.To develop a safety culture road map using

known best practices, emerging national standards, and previous work of MAPS and its members

2.For these best practices to become a community standard through a statewide call-to-action across all settings of care

MAPS Patient Safety Culture Workgroup

2010 continuedCulture Workgroup chooses domains to develop into road maps, using key safety subcultures identified in a meta-analysis.

What is Patient Safety? A Review of the Literature, Christine Sammer et al; Journal of Nursing Scholarship 2010

Timeline of Culture Initiative

2011 Domains assembled into one overall road

map Audit questions developed for each domain Key stakeholder groups identified to review

the full road map draft Tools/resources gathered for each domain

Timeline of Culture Initiative

2012 Final feedback received Road map finalized Kick Off meeting May 1

Timeline of Culture Initiative

The MAPS Safety Culture Road Map: A Bird’s Eye View

Road Map Design

Road Map Data Submission

Toolkit and Resources

Domain (#questions)% Best

PracticesGetting Started (46) 65%

Leadership (58) 63%Communication (16) 53%

Justice (29) 53%Teamwork (23) 18%

Learning Environment (37) 71%Engagement (29) 65%Sustainment (41) 61%

Next Steps

MAPS Conference• October 24-26, 2012

AHRQ Survey Group 1 Culture Webinars (AHRQ survey groups 2 & 3)• September 25, 2012 – AHRQ Getting Started• November 20, 2012 – Interpreting AHRQ results, Creating an Action

Plan• December 10, 2012 – Leadership• January 8, 2013 – Non-Punitive Culture• February 6, 2013 – Organizational Learning

AHRQ Survey Group #4 starting January, 2013 TeamSTEPPS Training

Questions?