Health Regulation Division
Collaborative Systems Change

• Cultivating a Culture of Safety
• Register for Upcoming Provider and Partner Orientations
• Systemic Mapping Sessions

The Minnesota Department of Health is committed to creating a culture of safety through collaboration with providers, partners and the people working to take care of our most vulnerable people in our health care system.

Enhancing a culture of safety begins by establishing a new tool and culture to study incidents collaboratively with partners, providers, policy makers, regulators and community members to

• Discuss challenges and vulnerabilities within complex systems without fear of retaliation
• Use a process for learning what is responsible for critical errors, rather than focusing who is to blame
• Increase staff engagement, morale and retention
• Develop solutions and improve culture
• Enhance equity and inclusion
• Improve the quality of life for people served by MDH licensed providers

The Department of Health is using the Collaborative Safety systemic review model to review incidents, such as infection control, Individual Abuse Prevention Plans, Tuberculous issues, and other safety incidents. Project planning began in April 2021 with the program launch in the summer of 2022. The first two systematic incident reviews or mapping sessions were hosted in the Fall 2022. Nearly 400 providers, partners and community members participated in an orientation session to learn more about Collaborative Safety.

MDH is using the Collaborative Safety systemic critical incident review model, developed by Collaborative Safety, LLC (collaborative-safety.com), to study and learn how decisions are made within complex regulatory systems. The goal is to understand what influences the decision-making process leading to an incident, collect data, and use the data to recommend solutions. Benefits include:

• Understand why a decision was made given the circumstances, the influences and systemic structures at the time of the incident.
• Move beyond focusing on people and outcomes and learn why people with good intent were faced with unintended consequences. Understand how systems fail and move to an understanding of how various parts of a system worked together to influence undesirable outcomes.
• Reduce unconscious bias in the review process.
• Improve the quality of life and outcomes.
• Develop a robust and proactive response to critical incidents dedicated to accountability, learning and improvement of Minnesota’s systems, rather than assessing blame.
• Develop recommendations for systemic changes

Subscribe to the GovDelivery Collaborative Safety list to make sure you receive the latest news and updates.

Cultivating a Culture of Safety

Cultivating a culture of safety requires an intentional commitment and approach that seeks to move an organization away from a culture of blame and toward a culture of accountability. Research shows that assigning blame might actually decrease accountability because it inhibits the ability of an organization to learn and improve.

The model draws from the same sciences that safety-critical industries, such as aviation and nuclear power, use to improve systems and develop a culture of safety. Advanced models engage employees in safety efforts, establish comprehensive approaches to analyzing adverse events and promptly act upon identified areas of improvement.

When our work addresses typical underlying systemic factors, our agencies and systems can begin to make critical advancements in promoting safe outcomes for people living in Minnesota’s long-term care facilities, families and employees.

Read more about the science and evidence of the review model on the Collaborative Safety, LLC website.

Register for Upcoming Provider and Partner Orientations

Collaborative Safety Provider and Partner Orientation sessions are where you will learn an exciting new way of collaborating with MDH’s Health Regulation Division to improve systems and safety. Dates for 2024 are coming soon. 

MDH’s Health Regulation Division aims to use safety science principles in alliance with providers, partners, facilities, and others interested in improving safety-related outcomes. Together we will learn to review issues and incidents outside of the regulatory environment to identify influences, barriers, potential solutions, and ultimately, improve the system.

Benefits

• Learn how to use safety science to improve responses to safety concerns
• Move beyond focusing on people and laying blame
• Learn about the multiple levels and factors influencing safety
• Understand why decisions are made within complex settings
• Support effective and lasting change to systems

Details

Orientation attendees will have the opportunity to see a presentation by Collaborative Safety, LLC and to learn about opportunities for providers, partners, policy makers and the public to identify the influences that cause violations in healthcare settings and discover ways to holistically address issues throughout the system.

“We’re excited about the opportunity to collaborate with providers and discover how we can make changes in our system, changes in the way we communicate with each other, changes in how we improve our systems, and create better outcomes in our health care systems,” explains to Catherine Lloyd, Manager, Office of Planning and Partnerships, MDH Health Regulation Division.

Systemic Mapping Sessions

Once providers and partners have participated in an orientation, you may also want to actively participate in analyzing a recurring issue or incident that would benefit from systems change. The Health Regulation Division is seeking interested providers and partners to suggest themes to focus on and to participate in a guided process that includes Human Factors Analysis (one on one interviews) and Systems Mappings (large group structured debriefing). Dates and mapping topics for 2024 are coming soon. Subscribe to the GovDelivery Collaborative Safety list to make sure you receive updates.

If you would like more information or if you have questions, please don’t hesitate to contact us.

• Catherine Lloyd, Manager, Office of Planning and Partnerships, MDH Health Regulation Division at Catherine.Lloyd@state.mn.us