Dragan Spremo, MRI Technologist at C.S. Mott Children’s Hospital pictured with MHA CEO Brian Peters and Sarah Scraton, MHA Keystone Center executive director.
The Michigan Health & Hospital Association Keystone Center a Dragan Spremo at University of Michigan Health C.S. Mott Children’s Hospital with the quarterly MHA Keystone Center Speak-up! Award on Oct 23.
The MHA Keystone Center Speak-up! Award celebrates individuals or teams in Michigan hospitals demonstrating a commitment to the prevention of patient or staff harm. Spremo is the second member of C.S. Mott Children’s Hospital to receive this recognition.
Spremo is honored for speaking up after noticing a foreign metallic object during a post-operative magnetic resonance imaging (MRI) scan of a patient’s hip. The pre-screening for metallic implants was negative, but Spremo noticed the foreign object in the patient’s gastrointestinal (GI) tract while reviewing the area intentionally imaged. The nominee immediately halted the scan and requested an X-ray be ordered, which confirmed metallic objects in the patient’s GI tract. Spremo’s swift action prevented delayed diagnosis and further GI tract damage.
“I’m truly honored to have received the MHA Keystone Center Speak-up! Award, and I want to express my gratitude to the entire team for their support and dedication,” said Spremo. “It’s a testament to the incredible work we do here at C.S. Mott Children’s Hospital and Michigan Medicine as a whole, in ensuring the safety and quality care of our little patients.”
Launched in March 2016, the MHA Keystone Center Speak-up! Award promotes a culture within healthcare organizations empowering staff to speak up about the quality or safety of patient care to foster continuous improvement and minimize institutional risk for both patients and providers.
“Safety is our top priority at Mott and it’s exemplary team members like Dragan that ensure our patients are kept safe and receive our highest quality of care each and every day,” said Luanne Thomas Ewald, MHA, FACHE, chief operating officer, C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital. “We’re so proud of Dragan for receiving this honor, speaking up for safety and role modeling our high reliability behaviors.”
Additional award finalists for the third quarter of 2023 include:
Socheat Chau and Julie Ketai, Trinity Health IHA Medical Group.
Laura Elders, University of Michigan Health-West.
Kevin Costa, Trinity Health Livonia.
“Dragan’s actions are a perfect representation of how diligent healthcare workers save lives,” said MHA CEO Brian Peters. “It was a privilege to celebrate Dragan and recognize C.S. Mott Children’s Hospital for its ongoing commitment to upholding a safety culture.”
“Thought Of equality- as if it harm’d me, giving others the same chances and rights as myself- as if it were not indispensable to my own rights that others possess the same.” ― Walt Whitman, Leaves of Grass
As we have discussed in these monthly reports in the past, I am incredibly proud that the MHA is committed to the health equity journey, which once again has been identified by the MHA Board of Trustees as one of our association’s strategic pillars for this program year. We have made progress, with much more work on the docket.
It is clear that to achieve health equity, there are multiple complex factors that must be addressed, and by now most of us in the healthcare field recognize how issues like food insecurity, transportation and housing all play a significant role. But there is another important consideration: the ability to participate in elections is one of the foundational elements of our American democracy, and just as our member hospitals are very engaged in removing barriers to healthcare access, Secure Automatic Voter Registration (AVR) removes a barrier for low-income Michiganders in the voter registration process.
In our health equity journey, we have learned that we can’t take certain things for granted. A small but illustrative example: when my physician prescribes for me an important medication that must be refrigerated, neither one of us has traditionally thought twice about it….but what if the patient in question can’t afford their utilities bill, or can’t afford a refrigerator to begin with? In the same manner, most of us don’t think twice about registering to vote, either by driving to the Secretary of State office or logging on to our computer. But what if we don’t have a car and can’t afford a computer or internet access?
At the end of the day, the MHA is an advocacy organization, so we know all too well that elections at both the state and federal levels have major consequences on healthcare funding, and a wide range of public policies that affect health insurance, pharmaceutical access and so much more. It is only logical that the very people who are directly impacted by these healthcare funding and policy decisions should have a voice in the process.
House Bill 4983 currently introduced in the Michigan Legislature would help expand representation in Michigan by using existing government data to register eligible voters. Referred to as Secure Automatic Voter Registration, those receiving Medicaid benefits would be automatically registered to vote, increasing the number of eligible voters by approximately 400,000 to 600,000. Medicaid was picked for several specific reasons. First, the agency already verifies citizenship, which is a requirement for voter registration. Only limited non-health data would be securely and electronically shared with election officials, who would use this information to either register nonregistered Michiganders or update existing registration. New or updated voters would receive a mailer providing an opportunity to decline the registration or correct the information.
Second, registering Medicaid enrollees would address election inequities. People of color, new U.S. citizens, young adults, people with disabilities and low-income individuals are disproportionately excluded from voting in the U.S. and overrepresented among Medicaid enrollees. We know Medicaid beneficiaries, in aggregate, tend to have additional challenges that impede their ability to register to vote, such as working multiple jobs, transportation access, available childcare and other needs.
Lastly, Medicaid provides a secure avenue to update voter registration rolls, as Medicaid offices routinely work with public health information and have experience securely sharing data. The agency routinely shares data securely with other agencies to determine access to additional benefits and with outside organizations that provide healthcare and other services. Such a system streamlines the voter registration process because the state already has the required information on file needed to register to vote. It also allows information to be updated more regularly, improving the accuracy of the voter rolls.
The MHA supports efforts to increase voter participation and we believe that Medicaid Automatic Voter Registration helps to achieve that goal while improving the efficiency of voter registration. The country still only has 69.1% of the voting-age population registered to vote and we can do better. We also see communities with higher voter turnout have better health outcomes, in part due to increased attention and resources from elected officials. In our quest to address inequities across the board, Medicaid AVR is a step in the right direction of improving access to resources within Michigan’s minority and underrepresented populations.
Patient Safety: A Case-based Innovative Playbook for Safer Care (Second Edition) is a recently published book that serves as a must-read resource for those seeking to enhance patient care and create a culture of safety within the healthcare industry.
MHA staff including Sam R. Watson, CPPS, CAE, senior vice president, field engagement, Gary Roth, DO, FACOS, FCCM, FACS, chief medical officer and Adam Novak, director, safety initiatives at the MHA Keystone Center, are contributors to the publication, sharing their expertise and findings in the foundational works of patient safety. Their insightful contribution can be found within the first chapter of the publication, which touches on topics of high reliability, patient experience and more.
The book can be purchased through SpringerLink, with the option of purchasing the electronic version or a physical copy.
Members with questions may contact Sam R. Watson at the MHA.
“Do the right thing. It will gratify some people and astonish the rest.”–Mark Twain
Last month’s CEO Report focused on our grave concerns with legislative proposals to mandate nurse staffing ratios, and the negative impact they would have on patient access to care. And we spent the entire month of September laser-focused on telling our story to elected officials, the media, business and healthcare trade groups and many others who care about the Michigan healthcare ecosystem. This advocacy work will continue, without question.
But the hallmark of the MHA and our members is to not simply advocate against bad public policy, but rather, to voluntarily do the right thing when it comes to the best interests of the patients and communities we serve. And when it comes to the safety and quality of the care we provide in Michigan hospitals, we indeed have a very special story to tell.
This year marks the 20th anniversary of the inception of the MHA Keystone Center, which was originally created in 2003 as a first-of-its-kind collaboration among hospitals to identify and implement practices that improve healthcare safety and quality and reduce cost. Acting as our safety and quality organization today, the MHA Keystone Center voluntarily identifies safety and quality improvement opportunities and develops solutions among Michigan hospitals to improve experiences for both patients and healthcare workers alike. The extraordinary partnerships among MHA Keystone Center hospitals have saved many lives as well as healthcare dollars.
It needs to be stressed that there is no mandate requiring participation; all Michigan hospitals and thousands of their team members voluntarily participate in MHA programs to improve the safety and quality of healthcare because of their missions to care for the sick and vulnerable. Because of our long history of success, a growing number of hospitals in other states are now part of MHA-led safety and quality initiatives. In addition, the hospital-based collaborative efforts first pioneered by the MHA Keystone Center have now been replicated in 48 of the 50 U.S. states and various other countries.
These initiatives are driven by evidence-based best practices and strongly supported by data. One great example of how engaged hospitals have seen great improvements on safety and quality outcomes is through the MHA Keystone Center’s leadership of the Great Lakes Partners for Patients (GLPP) Hospital Improvement Innovation Network (HIIN). Michigan hospitals saved 3,350 lives and avoided 25,304 harm events within hospitalized patients over a three-and-a-half-year period from Sept. 2016 to March 2020. In addition, our track record of outcome improvements includes the following:
Reduced the rate of CAUTI (catheter-associated urinary tract infection) events by 49% between 2012 – 2018.
Decreased CLABSI (central line associated blood stream infection) rates within ICUs by 35% between 2015 – 2018.
Reduced early elective deliveries by 68% between 2010 – 2018.
Reduced C. Diff rates by 15% from 2014 to 2017.
Reduced postoperative pulmonary embolisms and/or deep vein thrombosis by 22% from 2014 to 2016.
Reduced colorectal surgical site infections by 27% from 2014 to 2016.
This successful work led to the subsequent creation of the Superior Health Quality Alliance (Superior Health), which includes the MHA Keystone Center, along with our counterparts at the Illinois, Wisconsin and Minnesota hospital associations, and several other related organizations in the Midwest. Superior Health is funded by the federal government, which has clearly valued the ROI that is created by this work, both for Medicare and Medicaid patients for which they have a direct responsibility, as well as all patients.
On top of this work, the MHA Keystone Center has led hospitals on a high reliability journey for almost ten years now. Striving towards implementing and maintaining a high reliability culture means hospitals are focused on attaining zero preventable harm to patients, families and caregivers, making Michigan a safe place to receive care. Factors such as the pandemic, workforce shortages and increased rates of violence against healthcare workers all have emerged as challenges to this work. However, MHA Keystone Center member hospitals remain steadfast in their quest to reduce unintended harm in their facilities. One great example of how hospitals implement a high reliability culture is by stressing the importance of speaking up to prevent potential harm to patients or other staff members. Dozens of healthcare workers from hospitals throughout Michigan have been recognized by the MHA Keystone Center Speak-up! Award since it was launched in 2016. It is heartening that hospitals across the state, both large and small, urban and rural, have embraced an organizational culture that promotes and even celebrates anyone within the organization who speaks up to prevent harm.
Our to-do list in this realm is long and is constantly evolving. Based on the current needs of our membership, we are now focusing on reducing health disparities as our state strives to achieve health equity; improving maternal health outcomes; establishing age-friendly health systems; implementing solutions to address the opioid epidemic; facilitating person- and family-centered care; improving workplace safety; and providing emotional well-being support to healthcare workers through a partnership with the Duke Center for Healthcare Safety and Quality that has so far assisted 5,000 healthcare workers from 144 organizations throughout Michigan.
We know each of these efforts impact the health and well-being of countless Michiganders today. Thankfully, we have diverse funding support for our work; in addition to the federal government’s role noted above, the MHA Keystone Center has been funded by the Michigan Health Endowment Fund, and from our own hospitals who pay an annual fee for the services provided by our MHA Keystone Center PSO, a federally-certified Patient Safety Organization which collects adverse event data. But special recognition needs to be given to Blue Cross Blue Shield of Michigan (BCBSM), and their CEO Dan Loepp. Their initial support was instrumental in getting the MHA Keystone Center off the ground all those years ago, and we are now operating under a third round of very significant financial support from BCBSM that has been critical to our success.
Finally, I would like to acknowledge the great leadership of Sam Watson, our senior vice president of field engagement, and Sarah Scranton, our vice president of safety & quality, as well as the entire MHA Keystone Center Board of Directors, and of course the incredibly talented and dedicated MHA Keystone Center staff. We are proud to work every day with so many hospital leaders and clinicians who are dedicated to doing the right thing for patients and healthcare workers. At the end of the day, this is mission-driven work that all Michiganders can be proud of.
The MHA Keystone Center recently released the Michigan Caregiver Navigation Toolkit to guide hospitals and health systems implementing and maintaining caregiver navigation programs. These initiatives are designed to support caregivers in their role by providing connections, resources and education.
The Michigan Caregiver Navigation Toolkit aims to serve as a resource for healthcare staff looking to develop or improve the caregiver navigation program across their system. Although caregiving is relevant across all age groups, this toolkit is primarily intended for use on adults ages 18 years or older, with a special focus on older adults. The toolkit allows users to assess current structures to identify gaps and opportunities for improvement in caregiver support. It also provides guidance to create actionable plans for program development and expansion.
Attendees will learn about a new Michigan Caregiver Navigation Toolkit developed by the MHA Keystone Center, as well as how RUSH University Medical Center has expanded its Age-Friendly Health Systems initiative to incorporate caregiving best practices in its Caring for Caregivers model. Attendees will engage in a roundtable discussion about barriers and solutions to expanding caregiver programming in their organizations and across the state.
Attendees will also:
Learn about new initiatives and programs that focus on the health and well-being of patient caregivers.
Engage in an open discussion about potential barriers and solutions to adopting caregiver programming in your organization.
Participate in small breakout sessions to better learn each attendee’s unique needs to assist with adopting a new caregiver model.
Develop and leverage feedback to plan and evaluate how to expand caregiver programming across the state.
Executive and clinical leaders, patient safety officers, quality improvement personnel, directors of patient experience or compliance, care managers and caregiver program managers are encouraged to register by June 7 for the virtual roundtable.
The MHA Keystone Center PSO is hosting a Health IT & Risk Safety Safe Table from 12:30 to 3 p.m. June 14. The event will be held at Goshen Health, located at 200 High Park Avenue in Goshen, Indiana. Lunch will be provided at 11:30 a.m.
The free, interactive event will feature Goshen Health speakers Angie Lucas, manager, risk and safety, and Marlene Marks, director, clinical quality and performance improvement. They will present lessons learned at their health system and facilitate group discussions. Participants will gain insight into risk and safety considerations related to technology, including electronic medical record downtime, medication administration, mobility and competency assurance. During the breakout sessions, each group will create a gap analysis tool to assist in the evaluation of an organization’s processes and identification of potential vulnerabilities.
Directors or managers of risk management, directors of patient safety and directors of quality improvement are encouraged to register.
The MHA Keystone Center presented Cheryl Kay, RN, at E.W. Sparrow Hospital with the quarterly MHA Keystone Center Speak-up! Award, which celebrates individuals or teams in Michigan hospitals demonstrating a commitment to the prevention of patient or staff harm.
Kay was honored May 2 for advocating for her patient recovering from a cesarean section. The patient’s urine output was low and a rapid fluid infusion was ordered. However, Kay advocated to delay the infusion since the patient had preeclampsia. The patient did not receive the fluids and it was later discovered they had pulmonary edema, which could have been exacerbated had the infusion taken place.
“Caring for a mother so that she can care for her baby is one of the most fulfilling aspects of my job,” said Kay. “I’m proud to be able to advocate for my patients to ensure their quickest and fullest recovery so they can confidently tend to their new baby.”
Launched in March 2016, the MHA Keystone Center Speak-up! Award promotes a culture within healthcare organizations empowering staff to speak up about the quality or safety of patient care to foster continuous improvement and minimize institutional risk for both patients and providers.
“Team members like Cheryl consistently exemplify the high safety and quality standards we set for ourselves at Sparrow Health System,” said Paul Entler, D.O., Sparrow Health System’s Chief Clinical Officer. “She deserves to be recognized for acknowledging the complexity of her patient’s condition and ensuring all aspects were considered in their treatment plan.”
Additional award finalists for the second quarter of 2023 include:
Erin Harbour – RNC.S., Mott Children’s Hospital.
Susan Robinson – Helen Newberry Joy Hospital.
Sarah Allen – RN, Trinity Health Livonia Hospital.
“Establishing a culture that encourages staff to speak up is paramount to improving safety within Michigan hospitals,” said MHA CEO Brian Peters. “It is clear through Cheryl’s actions that the Sparrow Health System team is dedicated to advancing the quality of patient care, and we are thrilled to be celebrating her commitment.”
More information about the MHA Keystone Center Speak-up! Award, including criteria and a nomination form, are available online.
Healthcare workers across the state gathered April 13 in Southeast Michigan to discuss best practices for patient handling to ensure the safety of both the patient and the caregiver.
The MHA Keystone Center partnered with EarlyMobility.com to bring live safe patient handling demonstrations and interactive mobility equipment activities to more than 60 occupational therapists, quality and risk managers, nurses, physical therapists and physicians. Participants discussed the importance of safe, early and continuous mobility and how properly utilizing mobility equipment ultimately is in the best interest of patients and caregivers. Presenters also highlighted the cost and time savings that come from prioritizing revised best practices for patient handling and mobility.
The healthcare workforce is at higher risk of harm due to violence than other professional fields. Recent increases in workplace violence represent a major barrier to both staff and patient safety, prompting the need for additional resources, training and education.
The MHA Keystone Center Patient Safety Organization (PSO) Annual Meeting brings together national safety and clinical experts each year to discuss trending topics in healthcare.The 2023 meeting will be held virtually 9 a.m. to 3:10 p.m. May 3, focused on workforce safety and security. Speaker presentations include:
Stephen Weiler, emergency management specialist at HSS, an MHA Endorsed Business Partner, will provide an overview of HSS and its physical risk assessments.
Brian Uridge, deputy director at the University of Michigan Division of Public Safety will outline actions health systems can take to address and reduce healthcare violence. He will also provide examples of safety training procedures and policies for members to replicate.
