Award winner engages all sectors to improve quality
MAPS helps pass legislature on public reporting
Many health care quality proponents are under the impression that, while there is much they can do within the hospital setting to improve patient safety and quality, their impact is limited when it comes to much-needed changes in public policy. However, the Minnesota Alliance for Patient Safety (MAPS), one of the 2006 winners of the John M. Eisenberg Award for achievement in patient safety, has demonstrated the ability to engender important changes across a wide range of public and private sectors.
The other 2006 Eisenberg Award recipients, announced in October by the Washington DC-based National Quality Forum and the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, were: The IHI's Don Berwick, MD; Dr. Jerry H. Gurwitz, geriatric medicine and drug therapy expert (research category); the Pennsylvania Patient Safety Authority (second winner in the category of innovation in patient safety and quality at a regional level) and the Wichita Citywide Heart Care Collaborative (innovation in patient safety and quality at a local level). The four-year-old awards program honors Dr. John M. Eisenberg, former administrator of the Agency for Healthcare Research and Quality in Washington, DC.
Changing safety culture
MAPS is a partnership of the Minnesota Hospital Association (MHA), Minnesota Medical Association, Minnesota Department of Health, and more than 50 other public and private health-care organizations.
"MAPS started as a way to change the culture of safety outside the clinical setting," explains Bruce Rueben, a founding member and MHA president. "Going all the way back to the 1999 IOM report, there have been calls for collaboration and a change to a systems approach. What we felt at the MHA was that change certainly needed to occur inside the clinical setting but that change would not be as helpful if all stakeholders — lawmakers, the general public, the business community, health plans — all still looked at improving safety as something you did in a punitive way."
In order to get everyone moving on the same priorities, he continues, "We had to engage all those stakeholders in an effort to improve safety and move to a just culture." Apparently they succeeded: The Eisenberg judges cited MAPS for its "unique collaborative approach to improving safety through multiorganization cooperation and coordination."
The three driving forces behind its formation, says Rueben, were the MHA, the Minnesota Medical Association, and the Minnesota Department of Health, which, along with a few others, formed the executive committee.
"We first convened the group in 2000, and initially started with some priorities that were pretty easy to get agreement around — like educating patients about how to participate in their own safe care," Rueben recalls.
But the really significant achievement, which "truly coalesced this thing and created a bond," says Rueben, was the need to streamline a law in the state called the Vulnerable Adults Act. "Under this act, providers were expected to report all types of adverse events," he explains.
Too open-ended
The problem with the law, Rueben continues, was that "it was open-ended, subjective, and very poorly thought out, because depending on where you were in Minnesota any one of a half dozen bureaucrats made the decision as to whether an event was reportable or not; there was no uniform standard applied."
As the various MAPS stakeholder groups began to work together and developed a successful track record on things like patient education, they developed enough trust in each other to agree to use a national safety standard, says Rueben. "We agreed on the National Quality Forum's 27 so-called 'never' events," he relates. "At the same time, we developed technology that allowed hospitals to capture root cause analysis and corrective plans of action, and share them in a non-punitive way."
After two legislative sessions, MAPS succeeded in creating an opportunity — by law — for hospitals to share best practices and create a public reporting approach, which would engender accountability. "The Adverse Health Care Event Reporting law has become a national model," Rueben asserts.
Under this law, a report is issued by the Department of Health every January. "Any of these adverse events are listed by the facility, according to type of event; the accountability is very public," says Reuben. "And the hospitals are able to go into this web-based patient safety registry where they can see the root cause analyses and corrective action plans."
This reporting, he stresses, is not voluntary. "If a hospital has an adverse event occur, by law they must file a root cause analysis and corrective action plan. All other hospitals can have access to this and can put changes in place to prevent such events from occurring at their facility."
System flaws uncovered
Since the enactment of the law, MAPS has focused on identifying best practices around areas the reports have shown to be challenges. "We've had two public reports, so we're still trying to develop some experience and track record to show how helpful it is, but there is plenty of early anecdotal evidence that it's very useful," Rueben asserts.
One example, he shares, involved wrong-site surgery. "We had put into place protocols for correct-site surgery, but when we looked at the data in six different hospitals, each had had one adverse event involving wrong-site surgery on the vertebrae," he relates. "If you did not look at these hospitals all together, and it happened just once in one hospital, you might consider human error. But since we saw six in one year, it was clear the protocol in place was not adequate with respect to the spine."
The hospitals went back to their clinicians and put in an additional step — taking an image of the patient on the table — "and that seems to have substantially corrected the problem," Rueben asserts.
This would not have been possible without the collaborative model engendered by MAPS, he continues. "Working through MAPS stakeholders and being able to develop common goals has been a very bold step," he concludes.
Sources
For more information, contact:
- Amy Harris, Director of Communications, Minnesota Hospital Association, 2550 University Avenue W, Suite 350-S, St. Paul, MN 55114. Phone: (651) 603-3549.
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