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Laying a “SAFE” Foundation

Laying a “SAFE” Foundation. Julie Apold Sr. Director of Patient Safety Minnesota Hospital Association. 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:

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Laying a “SAFE” Foundation

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

  2. 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

  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: • Endorses the work • Clearly communicates goals • Regularly reviews progress toward goals • Supports adding resources as appropriate • 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) • With designated time!

  10. SAFE = S (Safety Teams/Org Structure) • Action 3: Identify gaps and develop action plans • The interdisciplinary team: • Reviews and updates the XX prevention program • Reviews data results at least quarterly and identifies strengths and opportunities • Develops a plan to prioritize and address improvement opportunities • 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 • 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: • When to stop the line • How to stop the line (verbal/non-verbal cue) • The chain of command to follow if not supported in stopping the line • 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?) • During shift change • Between departments/units • 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 • 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:

  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: • Data collection (Initial Phase) • Data analysis/interpretation: identifying the gaps (Planning Phase) • 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 14th MAPS Steering Committee approved • MAPS moving forward with Culture Roadmap and budgeting for a project manager Timeline of Culture Initiative

  23. 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 MAPS Patient Safety Culture Workgroup • 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 • CallyVinz, ICSI • Rob Welch, MD, VHA Upper Midwest • Linda Zespy, Project Manager

  24. Goal: To develop a safety culture road map using known best practices, emerging national standards, and previous work of MAPS and its members 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

  29. Road Map Design

  30. Road Map Data Submission

  31. Toolkit and Resources

  32. 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

  33. Questions?

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