• Strategy 1.1 - Survey of Patient Safety Task Force Members (Health System Chief Medical Officers and Others)

  • Responsible Party: Patient Safety Task Force
  • Data: Recent survey indicated a desire to pursue outside expertise to advise Taskforce work on 1) patient and family engagement; 2) achieving geriatric Zero Harm; and 3) eliminating diagnostic errors.
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 1.2 - Review Great Lakes Bay Region, State of Michigan and national data

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read, discussed and completed
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 1.3 - Review MiHIA Patient Safety data, papers, and research articles on patient safety and zero harm

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read and survey completed before the target completion date
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 1.4 - Determine what regional health systems are already doing and what else is possible; Focus is building on enhancing regional primary care capacity.

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read and survey completed before the target completion date
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

Completed In progress Not started

• Strategy 1.1 - Institute of Medicine Six Dimensions of Healthcare Quality

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read and survey completed before the target completion date
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 1.2 - HIH Four Focus Areas to Achieve Patient Safety

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read and survey completed before the target completion date
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

Completed In progress Not started

• Strategy 3.1 - Blended together IHI Focus Areas and IOM Six Dimensions with infographic and agreement to to adopt the combined as our framework

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read, discussed and completed
  • Target Completion Date: January 7, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

Completed In progress Not started

• Strategy 4.1 - Achieve Zero Harm status by January 2025

  • Responsible Party: Patient Safety Task Force
  • Data: Documents sent in pre-read, discussed and completed
  • Target Completion Date: January 1, 2025
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

Completed In progress Not started

• Strategy 5.1 - Set regional benchmarks for Patient Safety and Zero Harm in Health Systems

  • Responsible Party: Patient Safety Task Force
  • Data: "Several articles reviewed including NPSF, Joint Commission. In our Scan (less than 10% have done public Zero Harm target) The evidence can be seen on the front lines of care. Across the country, a cadre of diverse institutions—community hospitals, academic medical centers, and health systems—have taken dramatic steps toward zero preventable harm. None have compromised their ability to flourish financially and also serve their patients.
    
    Unfortunately, these institutions likely represent fewer than 10 percent of all hospitals. (An informal poll of knowledgeable colleagues agreed.) In part, that’s because their achievements have largely gone unrecognized by the public and their peers, both locally and nationally. Health Affairs Dec. 2019"
  • Target Completion Date: Feb-March 10, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

Completed In progress Not started

• Strategy 6.1 - Examine existing measurements inside regional hospitals

  • Responsible Party: Patient Safety Task Force
  • Data: Ongoing efforts are discussed monthly at Taskforce meetings, and innovative ideas/best practices shared.
  • Target Completion Date: Feb-March 10, 2020

• Strategy 6.2 - Crosswalk existing patient safety metrics to determine equivalencies and thresholds

  • Responsible Party: Patient Safety Task Force
  • Data: Shared as pre-read and in March 10 meeting
  • Target Completion Date: Feb-March 10, 2020
  • Progress Highlights and Significance: Crosswalk enables regional health systems to continue using their own patient safety reporting platforms while understanding inter-system safety equivalents.

• Strategy 6.3 - Defined common threshold measures

  • Responsible Party: Patient Safety Task Force
  • Data: Completed in March 10 meeting
  • Target Completion Date: Feb-March 10, 2020

Completed In progress Not started

• Strategy 7.1 - All regional hospitals agree

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun toward executing this objective
  • Target Completion Date: May 26, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 7.2 - Public statement

  • Responsible Party: Patient Safety Task Force
  • Data: Statement was released in early April, sharing the 2019 regional harm data. 2020 data is now under collection.
  • Target Completion Date: March - April 14, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 7.3 - Determining where measurement reported

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun toward executing this objective
  • Target Completion Date: March - April 14, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

• Strategy 7.4 - Engagements of patients and families within Zero Harm

  • Responsible Party: Patient Safety Task Force
  • Data: Systems have been developing and expanding Patient and Family Advisory Councils (PFAC).
  • Target Completion Date: March-April 14, 2020
  • Progress Highlights and Significance: Patient Safety mistakes are documented as the third leading cause of death. Taking aggressive action to change this will save hundreds of lives in our region and save thousands of people from adverse outcomes. 10% or less have secured regional zero harm agreements. This will drive dramatic action and the region can make a valid claim that it is in top 10% of health systems with Zero Harm agreements in place.

Completed In progress Not started

• Strategy 8.1 - Key messages

  • Responsible Party: Patient Safety Task Force
  • Data: Harm data recently explained via a letter to the region, with examples of the different levels of harm attached.
  • Target Completion Date: March - April 14, 2020
  • Progress Highlights and Significance: Setting a target of zero harm places our region in a leadership position for healthcare. It establishes our region as a preferred place to live and do business

• Strategy 8.2 - FAQ

  • Responsible Party: Patient Safety Task Force
  • Data: FAQ sheet also attached to the public letter sharing cumulative regional hospital harm data.
  • Target Completion Date: March - April 14, 2020
  • Progress Highlights and Significance: Setting a target of zero harm places our region in a leadership position for healthcare. It establishes our region as a preferred place to live and do business

• Strategy 8.3 - Letter to community

  • Responsible Party: Patient Safety Task Force
  • Data: Harm data recently explained via a letter to the region, with examples of the different levels of harm attached
  • Target Completion Date: March - April 14, 2020
  • Progress Highlights and Significance: Setting a target of zero harm places our region in a leadership position for healthcare. It establishes our region as a preferred place to live and do business

• Strategy 8.4 - Public statements 5/26 for all regional hospital CEO's with press release

  • Responsible Party: Patient Safety Task Force
  • Data: Press Release Link
  • Target Completion Date: May 2020
  • Progress Highlights and Significance: Setting a target of zero harm places our region in a leadership position for healthcare. It establishes our region as a preferred place to live and do business

Completed In progress Not started

• Strategy 9.1 - 5 years to make significant measurable progress on Zero Harm goal

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: 20205
  • Progress Highlights and Significance: Aggressive timeline is aimed at saving lives immediately and sustainability in the long-run.

Completed In progress Not started

• Strategy 10.1 - Explore culture change and patient/family inclusion

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: December 2020
  • Progress Highlights and Significance: A planning grant was secured to address medication safety for seniors. This will created a much better health and quality of life situation for our seniors. Older adults generally have the greatest use of medications and at the same time, suffer from adverse consequences associated with the use of these medications. These reasons include the concurrent use of multiple medications, changes in body physiology which requires special considerations for their medications, and the long-term use of medications which can lead to toxicity as well as micronutrient deficiencies which further harm their health. Recently several clinicians, foundations, and researchers have been raising alarm about these issues. A recent article in Health Affairs titled “Solving Medication Overload: America’s Other Drug Problem” expands on these critical issues. The article states “despite all of the benefits of modern medications, excess prescribing is putting millions of older people at grave risk of harm. It goes on to state that ”more than 40 percent of older adults are on five or more prescription medications, a threefold increase from twenty years ago. When over-the counter drugs and supplements are included, nearly 20 percent of older people take ten or more drugs, and it is not unusual for some older patients to be on more than two dozen different medications”.

• Strategy 10.2 - 4M4ME medication and seniors planning grant secured

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: December 2020
  • Progress Highlights and Significance: A planning grant was secured to address medication safety for seniors. This will created a much better health and quality of life situation for our seniors. Older adults generally have the greatest use of medications and at the same time, suffer from adverse consequences associated with the use of these medications. These reasons include the concurrent use of multiple medications, changes in body physiology which requires special considerations for their medications, and the long-term use of medications which can lead to toxicity as well as micronutrient deficiencies which further harm their health. Recently several clinicians, foundations, and researchers have been raising alarm about these issues. A recent article in Health Affairs titled “Solving Medication Overload: America’s Other Drug Problem” expands on these critical issues. The article states “despite all of the benefits of modern medications, excess prescribing is putting millions of older people at grave risk of harm. It goes on to state that ”more than 40 percent of older adults are on five or more prescription medications, a threefold increase from twenty years ago. When over-the counter drugs and supplements are included, nearly 20 percent of older people take ten or more drugs, and it is not unusual for some older patients to be on more than two dozen different

• Strategy 10.3 - IHI culture review tool and reference shared with health systems

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: October 2020
  • Progress Highlights and Significance: A planning grant was secured to address medication safety for seniors. This will created a much better health and quality of life situation for our seniors. Older adults generally have the greatest use of medications and at the same time, suffer from adverse consequences associated with the use of these medications. These reasons include the concurrent use of multiple medications, changes in body physiology which requires special considerations for their medications, and the long-term use of medications which can lead to toxicity as well as micronutrient deficiencies which further harm their health. Recently several clinicians, foundations, and researchers have been raising alarm about these issues. A recent article in Health Affairs titled “Solving Medication Overload: America’s Other Drug Problem” expands on these critical issues. The article states “despite all of the benefits of modern medications, excess prescribing is putting millions of older people at grave risk of harm. It goes on to state that ”more than 40 percent of older adults are on five or more prescription medications, a threefold increase from twenty years ago. When over-the counter drugs and supplements are included, nearly 20 percent of older people take ten or more drugs, and it is not unusual for some older patients to be on more than two dozen different

• Strategy 10.4 - Explore primary care focused actions: Care First (CMS Initiative) to address patient safety through primary care

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: October 2020
  • Progress Highlights and Significance: A planning grant was secured to address medication safety for seniors. This will created a much better health and quality of life situation for our seniors. Older adults generally have the greatest use of medications and at the same time, suffer from adverse consequences associated with the use of these medications. These reasons include the concurrent use of multiple medications, changes in body physiology which requires special considerations for their medications, and the long-term use of medications which can lead to toxicity as well as micronutrient deficiencies which further harm their health. Recently several clinicians, foundations, and researchers have been raising alarm about these issues. A recent article in Health Affairs titled “Solving Medication Overload: America’s Other Drug Problem” expands on these critical issues. The article states “despite all of the benefits of modern medications, excess prescribing is putting millions of older people at grave risk of harm. It goes on to state that ”more than 40 percent of older adults are on five or more prescription medications, a threefold increase from twenty years ago. When over-the counter drugs and supplements are included, nearly 20 percent of older people take ten or more drugs, and it is not unusual for some older patients to be on more than two dozen different

• Strategy 10.5 - Surveying private insurers whether they opted in to Care First

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: June 2020
  • Progress Highlights and Significance: A planning grant was secured to address medication safety for seniors. This will created a much better health and quality of life situation for our seniors. Older adults generally have the greatest use of medications and at the same time, suffer from adverse consequences associated with the use of these medications. These reasons include the concurrent use of multiple medications, changes in body physiology which requires special considerations for their medications, and the long-term use of medications which can lead to toxicity as well as micronutrient deficiencies which further harm their health. Recently several clinicians, foundations, and researchers have been raising alarm about these issues. A recent article in Health Affairs titled “Solving Medication Overload: America’s Other Drug Problem” expands on these critical issues. The article states “despite all of the benefits of modern medications, excess prescribing is putting millions of older people at grave risk of harm. It goes on to state that ”more than 40 percent of older adults are on five or more prescription medications, a threefold increase from twenty years ago. When over-the counter drugs and supplements are included, nearly 20 percent of older people take ten or more drugs, and it is not unusual for some older patients to be on more than two dozen different

• Strategy 10.6 - ARM4 Health Grant

  • Data: Care Journey our CMS data provider, is finalizing our baseline initiative data; The first release of National/State/County level performance reinforces the importance of this project; The ARM4Health project was presented at the Professional Association of Senior Services; The ARM4Health Implementation period begins with 17 different organizations throughout the region participating in the process.

Completed In progress Not started

• Strategy 11.1 - Implement projects defined in workplan

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: 2025

• Strategy 11.2 - Quarterly or annual updates on Zero Harm targets from all health systems

  • Responsible Party: Patient Safety Task Force
  • Data: Our regional data is as follows:
    Total Harm Events in Calendar Year 2019: 484 (with breakdown as follows):
    Mild or Minimum Temporary Harm: 401
    Moderate Temporary or Permanent Harm: 52
    Severe Temporary or Permanent Harm: 26
    Death: 5
    
    The Johns Hopkins data, when applied to our region, would suggest that somewhere between 300-700 deaths occur annually due to medical error. While our regional numbers might seem small, it is important to remember that the Johns Hopkins data includes all deaths attributable to medical error, not merely those deaths which occur in hospital settings and are identified using these standard tracking processes. Many additional causes of harm and death exist, such as those relating to inaccurate diagnoses or others caused by medication overload. We are working to eliminate all preventable harm both inside and outside our hospitals, but right now the most complete harm data which we have to share with the public comes exclusively from the inpatient setting.
  • Target Completion Date: Each year through 2025
  • Progress Highlights and Significance: In 2016, Johns Hopkins released the findings from a large study which reviewed years of medical death data. The results estimated that 250,000 deaths per year occur in the United States due to medical error. Those estimates place medical error as the third leading cause of death in our country, right behind heart disease and cancer.
    
    For decades, our regional healthcare systems have been working to eliminate medical error, but as the Johns Hopkins study revealed, we have more work to do. Two years ago, the healthcare systems of our region aligned to create the THRIVE Patient Safety Taskforce. Our main focus became the elimination of preventable medical harm, with a timeline of achieving this outcome by 2025. As part of this goal, the THRIVE Patient Safety Taskforce committed to not only share publicly the existing level of healthcare harm in our region, but also the efforts already underway to achieve and ultimately sustain Zero Harm.
    
    The regional inpatient hospitals (Ascension, Covenant, McLaren, and MidMichigan) are pursuing standards of excellence in their delivery of inpatient care. They employ robust patient safety processes to optimize the safety of all hospitalized patients, including daily safety huddles, dual patient authentication when administering medications, systematic assessment for breakdowns in safety protocols with subsequent protocol review and correction, peri-operative and operative improvements aimed at eliminating surgical errors, and physician-led case reviews where adverse outcomes are identified and addressed. These efforts are ongoing and ever evolving, and include many new and innovative approaches.
    
    Despite these efforts, we can do better. By creating the THRIVE Patient Safety Taskforce, we have built the sharing platform that will allow us to examine best practices and apply the newest safety science. In our commitment to accelerating the implementation of Zero Harm care, we also commit to building greater partnership with you, the wonderful people of our region.

• Strategy 11.3 - Engage broader parts of the healthcare ecosystems beyond acute healthcare systems

  • Responsible Party: Patient Safety Task Force
  • Data: Action has begun towards executing this objective
  • Target Completion Date: 2020-2022

Completed In progress Not started