Minnesota Alliance for Patient Safety Improving Regulation Discussion Operations Committee January 7, 2014

An organization with a culture of safety places less focus on events, errors, and outcomes, and more focus on risk, system design, and the management of behavioral choices. In this model, errors and adverse events are the outputs to be monitored; system design and the behavioral choices are the inputs to be managed and measured.

How Do We Measure a Regulator’s Success?

Effectiveness in: – Identifying risk – Mitigating risk or influencing risk management Efficiency – Resources required to protect our value(s) Two Primary Measures Measures of Regulatory Success

Accidents / sentinel events / adverse outcomes Near misses / close calls Inspector surveillance Digital surveillance External reporting by: – Operators – Individuals – Public Predictive methodologies How Do Regulators Learn About Risk in: Systems? Behaviors? Culture? How Do Regulators Learn About Risk in: Systems? Behaviors? Culture?

“Seeing” Socio-Technical Risk How Do Regulators Learn About Risk in: Systems? Behaviors? Culture? How Do Regulators Learn About Risk in: Systems? Behaviors? Culture?

Managing Socio-Technical Risk What the Regulator “Sees”

Managing Socio-Technical Risk What Cultural Surveys “See”

The Key Window for the Manager

Managing Socio-Technical Risk A Better View

“Seeing” the Entire Pyramid

. A Change in Focus: – From outcomes and errors – To system design and behavioral choices Organizations produce outcomes: To do this, they must design good systems and help employees make good choices Organizations produce outcomes: To do this, they must design good systems and help employees make good choices Individuals participate as components: To do this, they must make good behavioral choices within the system Individuals participate as components: To do this, they must make good behavioral choices within the system

Aviation Safety Action Partnerships (ASAPs) have demonstrated that less than 1% of the risks identified through these programs would have been known to the FAA outside these programs Identifying Risk through Partnerships Aviation Safety Action Partnerships (ASAPs) Benefits: More effective oversight by the regulator Improved regulatory compliance Better outcomes for the consumer Better outcomes for the public

“When your only tool is a hammer, you tend to see every problem as a nail.” -- Abraham Maslow

Next Steps For MAPS? Facilitated forum/Outside speaker – Board? – MAPS members? – Plus regulators/agencies? – Open to all? – Combination of above Pilot – Provider organization + regulator partnership (a la ASAP or North Carolina BoN)? Support for specific proposals – topic expertise