In This Issue

Welcome the Minnesota Department of Human Services to the MAPS Board of Directors


MAPS would like to introduce our newest Strategic Partner and MAPS Board member, The MN Department of Human Services (DHS). Scott Leitz, Assistant Commissioner at DHS and interim CEO for MNsure will be serving as the DHS designee. The MAPS board sought to add the perspective of a purchaser to help guide its work to ensure safe care everywhere. With DHS, MAPS has the added benefit of regulatory and provider perspectives as well as leadership from the state's largest purchaser of health care. MAPS continues to be a very broad health care coalition with representation across the continuum of health care and participation from both the public and private sectors. These combinations make MAPS a truly unique collaboration of organizations working to improve health care safety.


A full list of the MAPS Board of Directors can be found here.


Report on Safety in Skilled Nursing Facilities


This week the Office of the Inspector General released a report on safety in SNFs titled, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. The report seeks to raise awareness of nursing home safety and to reduce resident harm through methods used to promote hospital safety. In Minnesota, we have our efforts to ensure "safe care everywhere" well underway at MAPS. Through MAPS, long-term care organizations are already exploring ways to encourage reporting & learning, working to improve the culture of safety, seeking better regulations to support safety and working with patients and residents at transitions of care to make those transitions safer.


Minnesota's long term care associations, Aging Services of Minnesota and CareProviders, have already responded in a positive and proactive way to this report. MAPS applauds their work and will continue to help all Minnesota's health care organizations maintain their leadership in improving safety.



You have probably heard about the RARE campaign receiving the 2013 National John M. Eisenberg Patient Safety and Quality Award! All three organizations representing Minnesota and the RARE campaign are MAPS members and we could not be more happy for them. Shown below with the award, commemorative plaque and a pillow ("logo" for the campaign) are Kathy Cummings of the Institute for Clinical Systems Improvement, Tania Daniels from the MN Hospital Association and Vicki Olson of Stratis Health. All three were able to attend the event despite the Washington, D.C. blizzard! Again, congratulations!


MDH announces 2014 Patient Safety/Quality Mini-Grant Program!

For the third year, MDH recently announced the RFP release for the 2014 program.   All Minnesota hospitals and ambulatory surgical centers that are required to report under the Adverse Health Event Law are eligible to apply.


The focus for this year is:

  • Safe Surgery/Invasive Procedures
  • Any of the new reportable events-
  • Death or serious injury of a patient associated with the introduction of a metallic object into the MRI area
  • Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
  • Irretrievable loss of an irreplaceable biological specimen
  • Failure to follow-up or communicate laboratory, pathology or radiology test results


Applications are due by April 30th.  Please visit the MDH website for further information.

March, 2014
Dear MAPS Member -
We have had a busy winter with several ongoing projects. Please read below for updates about our LEAPT grant for transitions work, Conference 2014 updates, and other exciting news!
2014 MAPS Conference

MAPS is excited to provide additional details regarding its 2014 Conference (October 23 & 24, 2014 at the Minneapolis Marriott Northwest). This year's theme is "Safe Care. Everywhere"!


Plenary speakers have been confirmed and include Bryan Sexton, Val Ulstad, Scott Griffith and Allison Massari. There are four breakout session topic areas: Safety Across Settings, Workforce/Workplace issues, Hot Topics, and Safety at Transitions of Care.  Specific sessions include a HEN/LEAPT Overview, Employee Safety/Resilience, Mandatory Flu Shots for Employees, and Drug Diversion. 


The MAPS Patient Safety Award criteria are complete and will also soon be posted. They are modeled after the National John M. Eisenberg Patient Safety and Quality Awards, which are co-sponsored by the National Quality Forum and The Joint Commission.  2014 will represent the seventh presentation of the MN Alliance for Patient Safety awards. The emphasis for 2014 will be:
  • Safety Across Settings of Care
  • Measuring Safety Progress
  • Transitions of Care
  • Culture (including teamwork and communication)
  • Patient Engagement
For additional and ongoing information, please VISIT the Conference section of our website here. Registration will also be available there beginning in June.



Lastly, please consider including information about the MAPS Conference in your own newsletters and bulletins to help us spread the word!

A Decade of Experience with Adverse Health Event Reporting: MAPS applauds Minnesota's innovative approach to patient safety and 10-Year track record of success


Earlier this year, the Minnesota Department of Health released its 10th annual report on adverse events in hospitals and ambulatory surgery centers as well as an accompanying report and analysis of the 10-year history of the reporting process.


In 2003, Minnesota became the nation's first state to pass a law requiring all hospitals, and later ambulatory surgical centers, to report whenever a serious adverse health event (AHE) occurs and to conduct a thorough analysis of the event's causes. MAPS is enthused by the results. We've seen a downward trend in overall deaths and disabilities from these events over the 10 years of data collection. This trend and the infrequency with which these events occur is a step in the right direction. Even more encouraging is the progress that has been made, which is not reflected in the numbers - increased transparency, a willingness to implement and share prevention strategies, improved reporting and monitoring processes, and a culture shift that prioritizes the work needed to prevent errors and harm. 


While we've seen many successes, there is still room for improvement. The health care environment is becoming more complex. Health care reform has provided incentives for many new types of provider organizations, working together in new ways. As provider systems evolve, so must solutions to patient safety problems. MAPS supports the recommendation in the report to work with stakeholders throughout the state to expand the same commitment to transparency, learning and public reporting to all health care settings in Minnesota. In addition, patient safety in the next decade must include genuine input from patients, families and consumers. We need to develop new and effective ways to engage patients as partners in safe care. We have been a leader in the field of patient safety, but we must remain vigilant to ensure safe care everywhere in a very challenging environment.


MAPS Executive Director, Marie Dotseth, was interviewed by MPR for comment on the Adverse Events report. MAPS also submitted a press release and op ed related to the Adverse Events report. These documents can be found here.

Both MDH reports can be found on the MDH website.


An Update on the MAPS Grant


Phase two is well underway and the progress is exciting!  Findings from Phase one consumer research revealed both men and women are willing to accept leadership for their own health care.  They may approach it in different ways but both agreed upon the importance of their roles.  After 500 hours of consumer interviews, the group of respondents provided recommendations for tools that would help them avoid harm at transitions of care. 


MAPS is in the final stages of recruiting pilot sites to test the impact of the tools recommended by the consumers.  Each pilot site will distribute a packet to participants during a time of transition which will include a one page explanation of the folder contents, a note tablet, and a "refrigerator" magnet.  About a month after the transition, a survey will be sent by the MAPS evaluation subcontractor asking participants about the use and helpfulness of the packet.  A sample logo is shown below which will be used as a sticker on the outside of the folder and the campaign's logo.  As an additional resource, a website is being developed and will be released soon.




MAPS will continue to update its members on the progress of the grant.  Please contact us if you have any questions.

TeamSTEPPS National CONFERENCE to be held in Minnesota, June 11-12, 2014


As you are aware, teamwork and communications are vital components for a culture of safety.  Teamwork and Communication are one of the eight domains of the MAPS Culture Roadmap, and in our experience, one of the ares organizations struggle the most to implement. Team STEPPS is an evidence based, publicly available set of tools and best practices that can be utilized to improve teamwork and communication within healthcare organizations.


We encourage all MAPS member organizations to take advantage of this free conference and opportunity to learn best practices from across the country. The mission of the conference is to assist healthcare professionals in successfully implementing TeamSTEPPS®. Because the conference is free we encourage you to register early. A link to registration can be found here



Patient Safety Pamphlets Available!


"Patient Safety: Your Role," is a brochure designed to be used in hospital, pharmacy and clinic settings to better explain patients' roles in their own health care. This pamphlet, developed by the Minnesota Alliance for Patient Safety, is a resource to engage patients to become actively involved in their health care. 


The brochure is available in hard copy in multiple languages. To order, email MAPS or call us at (612) 362-3756.  An English version is available in PDF on our website here.

As you can see, there is a lot going on at MAPS!  Please contact us if you have any questions or concerns.

Marie, Lynette and Betsy
Minnesota Alliance for Patient Safety
1300 Godward St NE
Minneapolis, MN 55413

Minnesota Alliance for Patient Safety

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