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MAPS is joining in the Give to the Max Day movement, once again for 2023! To make a tax deductible donation, click here. 

Patient perceptions of safety are critical to the patient experience

Did you know that MAPS has a patient partner work group dedicated to the importance of in-person care partners?  Through that work they have met with multiple leaders to discuss the importance of those partners in ensuring safe care.  Dr. Tejal Gandhi, Chief Safety and Transformation Officer at Press Ganey has met with our team and listened to our concerns related safety.  This blog that she wrote addresses the importance of patient and family engagement for achieving safety…. “For many years, engaging patients and families in their care has been a foundational strategy for achieving patient safety. An essential component of this engagement is to better understand patient perceptions of safety. Patients and their family members can reliably observe medical error and other patient safety concerns that are often left undocumented in the electronic medical record and unnoticed by clinicians.”  MAPS believes that in-person care partners are critical to caring safely and that organizations can learn so much from listening to the voices of their patients and families.

View full article here: Patient perceptions of safety are critical to the patient experience (pressganey.com)


Spring 2023: Patients Partner with Lakewood Health System to Reduce Diagnostic Errors Through System Redesign

Written by: Ronn Lehmann

Diagnostic errors — the failure to establish and communicate an accurate and timely explanation of the patient’s health problem — is a significant problem in health care. Whether a diagnosis is delayed, wrong, or missed, the outcome can be grave for patients and providers. 

In partnership with the University of Minnesota, MMCI, Constellation, StratisHealth, and MAPS, Lakewood Health System undertook a project to decrease diagnostic errors by co-designing a new process to minimize the possibility of test result follow-up system failures that result in diagnostic errors. The project focused on diagnostic test follow-up in high-risk transitions of care for three specific tests: chest CT, chest X-ray, and blood/urine cultures.

The research began in 2019 with mapping of the current workflow for each test, chart reviews, and community surveys.

COVID hit in early 2020, and the project was delayed. But in March 2022, work resumed. Utilizing the data gathered in 2019, the next step was to take the identified opportunities for process improvement and to create an optimal future state for each of the three diagnostic tests.

Over two days in July 2022, the Lakewood team gathered at their facility in Staples, MN to create new process maps that would deliver increased reliability, safety, and efficiency.

From the beginning, the Lakewood organization’s leadership recognized the importance of including the perspective of patients and families to create a new process that is reliable, safe, and efficient. As a result, patients and community members were also part of the team. In addition to Lakewood area patients, two MAPS patient partners were also invited to join the July meeting. Along with Lisa Juliar of MAPS, Pat Lambert and I traveled north to join the team.

In addition to our volunteer work with MAPS, both Pat and I have been involved in several similar process redesign projects. These can be challenging in many ways, but the process utilized and results achieved by Lakewood was the best each of us had ever experienced.

The right people were in the room, with each part of the process represented, and everyone came with an openness to all ideas. There were no “silos”, territorial defensiveness, or protection of the status quo. The focus of all involved was on the patient and improving the process to reduce diagnostic errors and their impact on patients. The session was brilliantly organized and facilitated by Missy Lindow, Lakewood’s Director of Operations.

What we witnessed was how the often-frustrating complexity of health care can be improved through relentless commitment and collaboration. In a remarkably short amount of time, the new process flows for chest CT, chest X-ray, and cultures emerged; all tremendously improved over the former process flows.

Both Pat and I were grateful for the opportunity to be involved in this important patient safety project. In addition to contributing our perspectives as patients, we also got to witness first-hand the challenges faced by rural health systems and the work being done to make beneficial changes.

As Lakewood now moves to the implementation phase, we wish them well, and hope they have the same feelings we have: renewed energy and belief that things can get better for patients and providers.


Summer 2022: MAPS Issues Statement on Patient Safety accessible here.


Winter 2021: MAPS Hires New Executive Director accessible here.


MAPS Statewide Community Advisory Council Creates In-Person Care Partner accessible here.


SPRING 2019: Two new grant-funded safety improvement projects accessible here.


MARCH 2019Annual Adverse Health Events Features Patient Story accessible here.


MAPS Welcomes Three New Board Directors accessible here.


October 25, 2018: Executive Director Announced accessible here.


March 20, 2018 accessible here.


March 13, 2018 accessible here.


February 28, 2018 accessible here.


May 24, 2017 accessible here.


April 3, 2017 accessible here.


January 19, 2017 accessible here.


November 14, 2016 accessible here.



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We promote patient safety by encouraging collaboration between participants of Minnesota Health Care. Please join us in efforts to fulfill our mission.

Email us at: maps@mnpatientsafety.org

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