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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
Published on: February 16, 2011
Promoting collaboration and transparency in patient safety
Julie Apold1, Tania Daniels, Mark Sonneborn
1Minnesota Hospital Association, St. Paul, USA.
Background:
The Minnesota Alliance for Patient Safety (MAPS) collaborative was founded in 2000 by the Minnesota Hospital Association (MHA), the Minnesota Medical Association, and the Minnesota Department of Health.
Creating A Culture Of Learning, Justice, And Accountability:
MAPS made it a priority to make the health care workplace one that encourages learning from adverse events. MAPS is pioneering a statewide model of a "just" culture--one that supports learning yet holds individuals accountable for errors.
Legislative Changes:
In 2001, MAPS helped revise the Minnesota peer review law to allow hospitals to share key safety information through electronic databases such as the MHA Patient Safety Registry. The revisions paved the way for the 2003 landmark Minnesota Adverse Health Care Event Reporting Act, which encourages reporting of root cause investigations and steps taken by facilities to prevent recurrence. In 2003 the Patient Safety Registry, an electronic database, was expanded to serve as a confidential clearinghouse for facilities' reporting of adverse events.
Patient Safety Topics:
MAPS serves as catalyst for developing and disseminating best practices on topics such as health literacy, falls prevention, culture of safety, engaging patients, and consumers' medication tracking.
Conclusion:
The six-year collaborative effort by the many organizations comprising MAPS has led to a transformation in Minnesota's health care safety culture.
Insights
The Minnesota Alliance for Patient Safety (MAPS) collaborative fostered a "just culture" in healthcare, promoting learning from errors and accountability. This initiative transformed Minnesota
Area of Science:
- Healthcare quality improvement
- Patient safety initiatives
- Public health policy
Background:
- Established in 2000, the Minnesota Alliance for Patient Safety (MAPS) collaborative involved key state health organizations.
- MAPS prioritized creating a healthcare environment that learns from adverse events while ensuring accountability.
Purpose of the Study:
- To implement and evaluate a statewide model for a "just culture" in healthcare.
- To drive improvements in patient safety through collaborative efforts and legislative changes.
Main Methods:
- Revision of Minnesota's peer review law to facilitate secure data sharing.
- Development and expansion of the MHA Patient Safety Registry as a confidential reporting system.
- Dissemination of best practices in patient safety topics.
Main Results:
- Facilitated electronic sharing of critical safety information among hospitals.
- Enabled confidential reporting of adverse events through the Patient Safety Registry.
- Promoted best practices in areas like health literacy and falls prevention.
Conclusions:
- A six-year collaborative effort by MAPS significantly transformed Minnesota's healthcare safety culture.
- The initiative successfully promoted a culture of learning, justice, and accountability in healthcare settings.
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