1. Annual NPSF Patient Safety Congress May 2 – 4, 2007 Marriot Wardman Washington DC The Minnesota Model Alison Page, Chief Safety Officer, Fairview Health Services Tania Daniels, VP Patient Safety, Minnesota Hospital Association Shirley Brekken, Executive Director, MN Board of Nursing Ruth Martinez, Complaint Review Unit Supervisor, MN Medical Board Creating a Learning, Just, and Accountable Culture- A Statewide Change Washington, D.C. Thursday, May 3, 2007 1:30-3:00pm

2. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future We need….. A culture that truly supports learning A common understanding about how to treat people when things happen

4. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future The Minnesota Agenda Formation of a stakeholder group - The Minnesota Alliance for Patient Safety Change state law Developed principles of justice, learning and accountability Change the policies and practices of: –The Boards –The Dept of Health –Delivery systems

5. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Minnesota Alliance for Patient Safety (MAPS) Founded in 2000 by the Minnesota Hospital Association, Department of Health and the Medical Association Over 50 broad-based stakeholders as members Focuses on changing the environment

6. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future MAPS Mission Promoting optimum patient safety through collaborative and supportive efforts among health care organizations in Minnesota Goals –Improve patient safety –Improve culture for patient safety –Mobilize community resources –Develop and implement safety education

7. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Changes to State Law Revised Peer Review Law to break down silos (2000) –Allowed sharing safety information across facilities The Vulnerable Adult Act (In place since 1975) - Did not encourage reporting- Punitive investigation, made public - Definitions gray Needed to create a non-punitive system with clear reporting definitions

8. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future New Patient Safety Reporting Law Effective July 2003 Goal of the new law: Not …to punish errors by health care practitioners or health care facility employees Instead…to balance quality improvement and accountability for public health & safety Hospitals, out patient surgical centers, and boards that regulate physicians, PAs, nurses, pharmacists, and podiatrists report any of the NQF 27 serious reportable events

9. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Patient Safety and Regulation

10. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Attitudes Change Improved relations Efforts by regulatory entities…boards and MDH to improve relationships with delivery systems Collaboration with other health licensing boards increases

11. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Attitudes Change Efforts Initiation of educational outreach Exploration of alternatives to formal disciplinary action Legislative changes

12. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Managing Impairment 1992 HIV/HBV confidential monitoring program 1994 Health Professionals Services Program

13. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future 1993 Non-disciplinary Corrective Action

14. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Fairview’s Journey

15. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Building a Just Culture within Fairview Desired to shift Fairview culture – –Open, learning and non-blaming Used James Reason’s algorithm Recognized Fairview could not pursue a culture of justice alone –Need consistency with Department of Health & Professional Boards

16. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Moving to a Just Culture Create Awareness & Set a Vision Establish “just” policies Embed “just” practices

17. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Create Awareness & Set a Vision April 2004 – MAPS Summit – David Marx, JD, facilitator – Exposed 40 top executives & clinical leaders to just culture October 2005 – Built awareness at the broader level – trained 350+ operational & clinical leaders November 2006 – 2007 – MN Just Culture Collaborative with David Marx, JD

18. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Why “just” policies were needed We queried staff, managers, and physicians regarding their current perceptions of the use of discipline in response to a person’s behavior - depending on whether or not the behavior resulted in harm.

19. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Why “just” policies were needed How would your organization deal with a surgeon who used an unauthorized piece of equipment? Percentage of those who believe Fairview would discipline the surgeon….if: NO harmful outcome ‾19% of staff ‾0% of managers ‾11% of executives ‾0% of physicians Harmful outcome ‾29% of staff ‾50% of managers ‾14% of executives ‾45% of physicians

20. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Establish “just” policies Embedded principles into system policies – Policies: Corrective action Performance appraisal Problem resolution process Management rights and responsibilities Event reporting and investigation – Wording changed to incorporate “just culture” language Categorize behavior – error, at-risk or reckless Management response – console, coach or punish

21. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Event reporting and investigation The just culture algorithms provide a common philosophy and language that was badly needed. Reporting system asks questions that help understand behaviors and systems. Investigation includes why a person behaved in a certain way.

22. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Embedded “just” practices Incorporate into system wide initiatives – Hand washing – Medication reconciliation – Patient identification – Team Training – Safe patient handling New employee orientation New manager training Medical leadership training

23. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Creating a culture safety is about understanding and addressing two things: Systems and processes Human behavior

24. Judging behavior in a “Just Culture” Reckless Behavior Intentional Risk-Taking Manage through: Remedial action Disciplinary action At-Risk Behavior Unintentional Risk-Taking Human Error Product of our current system design Manage through changes in: Processes Procedures Training Design Environment ConsoleCoachPunish Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness

25. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Embed “just” practices - Education New employee orientation – Share our reporting system – Demonstrate how we hold people accountable for behaviors vs. outcomes Management Training – Video – Online Education through www.justculture.orgwww.justculture.org

26. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Buy-in Acknowledgement that discipline is not always the most effective way to address deviations from practice standards Recognition that remediation and rehabilitative efforts are often enhanced by continued practice in a supportive environment Successful remediation of individual practitioners and improved patient safety require collaboration between regulators and the larger health care delivery system

27. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Minnesota Statement of Support Given that: Medical errors and patient safety are a national concern to all involved in health care delivery. We are legally and/or ethically obligated to hold individuals accountable for their competency and behaviors that impact patient care. A punitive environment does not fully take into account system issues, and a blame-free environment does not hold individuals appropriately accountable

28. We resolve that our organization will: Strive for a culture that balances the need for a non- punitive learning environment with the equally important need to hold persons accountable for their actions. Seek to judge the behavior, not the outcome, distinguishing between human error, at-risk behavior, and intentional reckless behavior. Foster a learning environment that encourages the identification and review of all errors, near-misses, adverse events, and system weaknesses.

29. Promote the use of a wide range of responses to safety- related events caused by lapses in human behavior, including coaching, non-disciplinary counseling, additional education or training, demonstration of competency, additional supervision and oversight and disciplinary action when appropriate to address performance issues. Support and implement systems that enable safe behavior to prevent harm Work to share information across organizations to promote continuous improvement and ensure the highest level of patient and staff safety. Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to provide the safest possible environment for patients.

30. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Our Goal The behavior of people involved in care delivery in the state of Minnesota will be judged using a common philosophy and a common set of principles across healthcare organizations, the Department of Health, the professional boards and professional associations

31. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Lessons Learned This is not intuitive…not easy…culture change takes time Coalition of broad stakeholders including the regulatory boards and department of health is instrumental Differing perspectives should not result in exclusiveness

32. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future Lessons Learned Focus on the mission to protect the public and promote the public interest Concrete action needed to make “just culture” tangible Community education--the public still wants to blame the health care provider, rather than understand a systemic issue

33. 2007 NPSF Patient Safety Congress Learning from the Past, Creating the Future It takes…… Commitment Collaboration Communication