Collaborative Safety at the Health Regulation Division

• Creating a Culture of Safety with Employees, Providers, Partners and Policy-makers to Protect Minnesota’s Most Vulnerable People
• Cultivating a Culture of Safety
• Get Involved

Creating a Culture of Safety with Employees, Providers, Partners and Policy-makers to Protect Minnesota’s Most Vulnerable People

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 Plan, 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

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.

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Systemic Mapping sessions

Interested in participating in a critical incident review to learn about opportunities for providers, partners, policy makers and community members to identify the influences that cause violations in healthcare settings and discover ways to holistically address issues throughout the system. Contact Catherine Lloyd at catherine.lloyd@state.mn.us to discuss opportunities to participate.

Orientation and webinar sessions

Interested in attending a Collaborative Safety orientation or webinar session by Collaborative Safety, LLC, to learn about opportunities for providers, partners, policy makers and community members to identify the influences that cause violations in healthcare settings and discover ways to holistically address issues throughout the system.

• Who: partners, providers, policy makers and community members. As a leader in public health, you have an integral role in developing solutions to systemic health and safety issues across Minnesota. Join us to learn more about safety science at the orientation session.
• What: The orientation will give providers and stakeholders an opportunity to learn more about a new method HRD will use to evaluate past incidents, with the goal.
• When: 2023 dates coming soon
• Session overview: This orientation session will provide a foundational understanding of safety science that will foster a collaborative effort with partners, providers, policy makers and community members. The orientation will give providers and stakeholders an opportunity to learn more about the method HRD will use to evaluate past incidents, with the benefit of. We want to learn what influences the decision-making process and recommend solutions for improved outcomes. Safety science offers providers and regulators the opportunity to review critical incidents at a deeper level to discover issues, gaps or opportunities to improve the system and improve outcomes. It offers the opportunity to
  • 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.
  • Reduce unconscious bias in the review process.
• All partners are needed to make it a successful effort, MDH, partners, providers, policy makers, community members and more. All volunteers are needed for project success by dedicating time to attending meetings and to share input in incident focus area(s) and to develop systemic transformations mutually.

The Collaborative Safety initiative creates a system to develop and maintain looking critically at our systematic processes and ourselves.

“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.” said Health Regulations Division Director Maria King.

Register now to learn about Collaborative Safety and future opportunities to collaborate with MDH on developing strategies to address systemic issues in licensed home care and assisted living facilities. Providers with interest in learning more about Collaborative Safety or opportunities to participate in critical incident reviews can register to receive news and updates about trainings and opportunities.