1. Place picture here Julie Apold Sr. Director of Patient Safety Minnesota Hospital Association Laying a “SAFE” Foundation

2. MHA Calls-to-Action Brief 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

3. 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

4. Patient Safety Road Maps

5. MHA Statewide Calls-to-Action

6. Road Map Structure  SAFE  Topic-specific Gap Analyses

7. “SAFE”

8. SAFE = S (Safety Teams/Org Structure)  Action 1: Secure endorsements and resources for XX Prevention Program Leadership: o Endorses the work o Clearly communicates goals o Regularly reviews progress toward goals o Supports adding resources as appropriate o Designates a senior leadership sponsor

9. 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!

10. SAFE = S (Safety Teams/Org Structure)  Action 3: Identify gaps and develop action plans The interdisciplinary team: o Reviews and updates the XX prevention program o Reviews data results at least quarterly and identifies strengths and opportunities o Develops a plan to prioritize and address improvement opportunities o Commissions subgroups as needed

11. SAFE = A (Access to Information)  Action 1: Track progress on process and outcome measures Observational audits Inter-rater reliability Capture adverse event details

12. 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

13. 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

14. 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 line o How to stop the line (verbal/non-verbal cue) o The chain of command to follow if not supported in stopping the line o Clear communication to staff from managers and leadership that staff will be supported if they speak up

15. SAFE = F (Facility Expectations)  Action 2: Education for staff and physicians Orientation Annually

16. 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 change o Between departments/units o To other facilities

17. 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

18. 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”

19. The MAPS Journey to Developing the Culture Road Map

20. 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 MHASteve Meisel, Fairview Health Services Diane Rydrych, MDHCally Vinz, Gary Oftedahl, ICSI Marie Dotseth, Dotseth ConsultingSusan Peterson, Anoka Metro Regional Treatment Center Jennifer Lundblad, Kelly O’Neill, and Denise White, Stratis Health Rob Welsch, VHA Upper Midwest Becky Schierman, MMA

21. Timeline of Culture Initiative 2010 – Exploratory Work Group  Took 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

22. 2010 – Exploratory Work Group Recommendations  There is a role for MAPS to address a culture of safety that expands across health care settings  Provide a framework of best practices, implementation support, and measurement  Develop best practices road map and guide health care providers who are embedding a culture of safety within in their organizations  Create a community standard through a statewide call-to-action across all settings of care 2010 MAPS Governance Decisions  July 14 th MAPS Steering Committee approved MAPS moving forward with Culture Roadmap and budgeting for a project manager Timeline of Culture Initiative

23. 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

24. 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

25. 2010 continued Culture 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

26. 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

27. 2012  Final feedback received  Road map finalized  Kick Off meeting May 1 Timeline of Culture Initiative

28. The MAPS Safety Culture Road Map: A Bird’s Eye View GETTING STARTED Endorse culture effort Analyze survey results Develop steering committee Develop plan Identify champions Provide education on safety Conduct culture survey LEADERSHIP Strategies/tactics for these leaders to set clear patient safety expectations: Governance Clinician leaders CEO/administrator Managers COMMUNICATION Structured communication process Structured handoffs Stop-the-line policy JUSTICE MAPS statement of support Key stakeholder groups Just/accountable education HR practices RCA process Clinical practices Hardwiring/ sustaining TEAMWORK Readiness assessment Facilitator recruitment Team training Gap assessment Workplans LEARNING Reality rounding Reporting system RCA process Use of report data Patient/Resident/Client and Family ENGAGEMENT Soliciting input Pt/family empowerment processes Effective disclosure Health care literacy and cultural competence SUSTAINING THE OVERALL CULTURE INITIATIVE Measurement Review of plan Metrics analysis Education Course corrections/new actions Evaluation of performance Dissemination of data/findings/actions

29. Road Map Design

30. Road Map Data Submission

31. Toolkit and Resources

32. Domain (#questions) % Best Practices Getting 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%

33. 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

34. Questions?