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					   Innovation in Perinatal Care: Learnings
 from Phase II of the Premier/IHI Perinatal
           Innovation Workgroup




Presented by:
Carla Provost, RN – Baystate Health
Cathy Ivory, RN – Johnson City Medical Center, MSHA
Sue Gullo, MS, RN – IHI                                                 June 23, 2006
Kathy Connolly, RN, MSEd, CPHRM – Premier             Premier Breakthrough Conference
Median Medical Malpractice Awards for                                                                                                                                                                                     Five recurring clinical issues are responsible
Specific Liability Situations, 1997-2003 *                                                                                                                                                                                for majority of perinatal harm and associated
                                                                                                                                                                                                                          obstetrical professional liability:
                                $2,500,000
$2,600,000
$2,400,000                                                                                                                                                                                                                 • Failure to recognize fetal distress/non-reassuring
$2,200,000                                    $1,550,000                                                                                                                                                                     fetal status
$2,000,000
$1,800,000
                                                                                                                                                                                                                           • Failure to effect a timely cesarean birth
$1,600,000
             $1,266,500
                                                                                                                                                                                                                           • Failure to properly resuscitate a depressed baby
$1,400,000                                                         $975,000
                                                                                                                                                                                                                           • Inappropriate use of Oxytocin/Cytotec
$1,200,000
$1,000,000                                                                                                $705,000
                                                                                                                                                                                           $753,901                        • Inappropriate use of vacuum/forceps
  $800,000                                                                                                                                     $500,000 $500,000
                                                                               $410,000                                $384,500
  $600,000
  $400,000
  $200,000                                                                                                                                                                                                                      JCAHO Root Causes of Perinatal
        $0
                                                                                                                                                                                                                                     Deaths and Injuries
                                                                                                                                                                   Nonsurgical Treatment
                                                                                                                       Negligent Supervision
                                                                   Diagnosis
             Cancer Diagnosis




                                               Delayed Treatment




                                                                               Lack of Informed Consent
                                 Childbirth




                                                                                                          Medication




                                                                                                                                                                                           Medical Malpractice, Overall
                                                                                                                                               Negligent Surgery




                                                                                                                                                                                                                                               (1995-2004)




* Source: Jury Verdict Research® - Horsham, PA
     What is Idealized Design of
           Perinatal Care
• Idealized design enables the system to do
  better in the future than the best it can do
  today.
• Idealized Design ™ has been developed
  by the Institute for Healthcare Improvement
  (IHI) to bring together organizations that are
  committed to comprehensive system
  redesign.
    Mother and family as the source of control
                         Productive
                        conversations


             Prepared and activated teams
                 RELIABLE PROCESSES
Prepared and
                                                 Informed & ready
activated                                          receiving unit;
mom                      FIRST    SECOND          Stabilized mom
             EVALUATE
             ADMIT      STAGE      STAGE   BIRTH      and baby
                        LABOR      LABOR

    PREVENT          IDENTIFY           MITIGATE

          APPROPRIATE INFRASTRUCTURE
   The Process for Innovation

Phase I: 16 Teams
• Premier
  – Premier‟s Healthcare Informatics and
    Insurance Management Services
• Ascension Health
  – Perinatal Safety Alpha Ministries
Phase II: 26 Teams (10 New Teams)
              Design Targets

• Reduce neonatal harm to 3.3 per 1000 births or
  less
• Patients state that 95% of the time their wishes
  are known to the entire team and respected
• The care team reports that a 50% improvement
  in culture survey score.
• All claims or allegations may be defended
  because 95% or more of claims meet each
  institution‟s internal standards for defense (e.g.,
  consistent documentation, no lapses in
  documentation, no lapses in communication)
    What does this have to do with
             reliability?
• What: Best science for the care we deliver
  – Research and expert opinion
• How: the method we use to deliver that care
  – this is the focus of our work- discovering the way
    to reliably deliver the best care every time
• Why: use of reliable design and an
  articulated goal for each of the processes of
  care that we think will make the most
  difference and are outlined in the model.
                Our work

      Phase I                  Phase II
• Elective Induction    • Common Interpretive
  Bundle                  Construct
• Augmentation Bundle   • Reliability
• Application of        • Perinatal Trigger Tool
  reliability model     • Patient Preference
• Common language       • Identification of risk
• Communication and
  Teamwork Training
                    What are our outcomes?

                                     Teams Reporting Birth Trauma
                                        National Average 6.74%

               7
               6                                                              Hospital 1
Birth Trauma
 Percentage




               5                                                              Hospital 2
               4
                                                                              Hospital 3
               3
               2                                                              Hospital 4
               1                                                              Hospital 5
               0                                                              Hospital 6
                   Jan'05   March   May   July     Sept   Nov   Jan   March   Hospital 7
                             '05    '05    '05      '05   '05   '06    '06
                                                                              Hospital 8
                                                 Months
   Johnson City Medical Center
Progress with Premier/IHI Perinatal
  Innovation Workgroup Project
    Catherine H. Ivory, RNC, MSN
      Clinical Nurse Specialist
            June 23, 2006
JCMC Augmentation Bundle
Augmentation Composite
Induction Bundle
Induction Composite
Perinatal Adverse Events
     Project Success to Date
• JCMC Trigger Tool database was the
  subject of the May 2006 IHI All-Team
  Conference Call.
  – Database developed jointly between PI and
    CWH CNS
  – Several teams have requested the database
    to assist with their own data collection
• CNS presented at OB/GYN Grand Rounds
  on May 10 about OB Emergency Drills
     Project Success to Date
• SBAR Shift report tool to be piloted as
  “small tests of change” in June.
• System-wide SBAR is progressing. CWH
  tools used as examples
• 3-Hour Introductory EFM workshop
  scheduled July 5 for new OB residents
  and new nursing team members together.
                 Challenges
• OB Emergency Drills require significant
  coordination and resources from all disciplines
  – OB/GYN
  – Anesthesia
  – Nursing
• System-wide deployment of Rapid Response
  Teams (RRT) brings particular opportunities for
  OB and NICU
  – Unique patient population requires OB/NICU specific
    rapid response
  – Role and proper education in OB about appropriate
    use of JCMC RRT for non-OB emergencies.
Progress with Premier/IHI Perinatal
Innovation Workgroup Project

   Carla Provost, RN
   Baystate Medical Center
   Springfield, MA
   June 23, 2006
BAYSTATE TAKES LEAD!
Baystate Medical Center‟s, Wesson
Women & Infants‟ Unit, #1 in the state for
both patient satisfaction and patient
safety! Women are beating down the door
to deliver at BMC. What‟s their secret?
We tested . . .
    Pitocin Bundles
      Designed and tested checklists

      Staff communication

      Met with one provider

      Met with selected group

      Scheduled induction protocol
       developed
      Support of Chairman
         NO   PAPER, NO PIT!
            We tested….

• Med   Teams – SBAR
  •Development and distribution of SBAR
  cards
  •Daily rounds including anesthesia and
  case managers – currently brainstorming
  ways to get nurses back to rounds –
  Afternoon rounds need a makeover
We implemented . . .

    Bundles!
        Added to our electronic record
    SBAR!
        Situational awareness DVD premier coming soon
    Common Language!
        Our EFM assessment card has changed to reflect
         NICHD terminology changes
        Development of educational CD for all staff
    Teamwork – Teamwork -Teamwork
Most promising changes

  The awareness of our unit‟s patient
   safety focus. Staff appreciate the teams
   challenge of the „unspoken‟.
  Patient satisfaction is at an all time high.
Assumptions previously held
that we challenged
  Assumed provider would not want to
   hear opinion of tracing…
  Reminded all that these changes were
   beneficial to the patient; they were not
   implemented for any other reason, or
   with another goal in mind.
For more information about Premier/IHI Perinatal
Innovation Project, you may contact:
   Premier, Inc.
          Kathy Connolly (704) 733-5096
          Email: kathy_connolly@premierinc.com

          Kevin Davidson (858) 509-6848
          Email: kevin_davidson@premierinc.com

     IHI (Institute for Healthcare Improvement)
            Sue Gullo (603) 663-4396
            Email: sgullo@IHI.org
          Appendix – Premier/IHI Perinatal
              Innovation Workgroup




Presented by:
Carla Provost, RN – Baystate Health
Cathy Ivory, RN – Johnson City Medical Center, MSHA
Sue Gullo, MS, RN – IHI                                                 June 23, 2006
Kathy Connolly, RN, MSEd, CPHRM – Premier             Premier Breakthrough Conference
   Reasons for the Reliability Gap In
             Healthcare
• Current Improvement methods in healthcare are highly
  dependent on vigilance and hard work

• The focus on benchmarked outcomes tends to
  exaggerate the reliability within healthcare hence giving
  both clinicians and leadership a false sense of security

• Permissive clinical autonomy creates and allows wide
  performance margins

• The use of deliberate designs to achieve articulated
  reliability goals seldom occurs
   Profile of Successful Teams

• Strong senior            • Team members from
  leadership and/or          the clinical frontline
  corporate support.         who are involved and
Example- there will be       empowered to identify
  no elective inductions     and implement
  <39 weeks at our           changes.
  facility                 • Presented all
• Physician                  information with the
  Champions                  science behind it.
                Bundles

• Individual elements based on solid science

• Emphasis initially on process rather than
  outcome

• Based on failure modes

• Eventual endpoint is outcome
  improvement
    All or None Measurement

• All-or-none measurement fosters a system
  perspective, not only parts.
• Offers a more sensitive scale for
  assessing improvements.
• The number of measures in the set should
  be small (perhaps 4 to 8) and each one
  should measure performance with respect
  to the specified elements of good care.
        The Oxytocin Innovation Bundle


Elective Induction           Augmentation Bundle
  Bundle
• Gestational Age >/= 39     • Documentation of
  weeks                        Estimated Fetal Weight
• Reassuring Fetal Status    • Reassuring Fetal Status
• Pelvic Exam prior to the   • Pelvic Exam prior to the
  start of Oxytocin            start of Oxytocin
• Recognition and            • Recognition and
  management of                management of
  Hyperstimulation             Hyperstimulation
    Tools Developed for Bundle
        Success-Example
•   Hard stop in booking elective cases- no
    elective inductions (or elective
    cesareans) prior to 39 weeks GA.
    1. Stopped at the booking point
    2. Prenatal record required on unit prior to
       booking of any procedure.
    3. Supported by the Physician Champion and
       backed up by the OB/GYN Department.
     Tools for Bundle Success
• One stop documentation- all bundle elements
  rolled into a sticker/stamp for physician progress
  note as a reminder of what needs to be
  documented prior to the initiation of pitocin.
• Decision aids/reminders built into the system.
• Everyone on the same page and understanding
  of expectations.

                Make it easy!
               Example
                   Progress Note
    Induction Reason:____________________
             Augmentation of Labor
      ASSESSMENTS – (complete all that apply)
        Gestational age ___________ weeks
Estimated Fetal Weight (check appropriate category)
      Small for Gestational Age ( < 2500 gm)
        Appropriate for Gestational Age
     Large for Gestational Age ( ≥ 4000 gms)
                    Pelvic Exam
               Dilatation _______ cm
              Effacement _______ %
Presentation Vertex  Yes Other:______________
               Station ____________
       Membranes  Intact  Ruptured
   FHR Pattern  Reassuring  Non-reassuring
              OTHER HISTORY/DATA:
Thomas
Jefferson
University
Hospital
  Effective Communication and
       Common Language
• Agreed upon standardized language for key
  clinical terms

• Used in all professional communication (verbal
  and medical record documentation)

• Notification of other members of the team using
  communication styles that include clear, concise
  and accurate information conveyed with
  appropriate urgency. Example- SBAR
EFM Education: Physicians and
  Nurses Learning Together
• Everyone with similar knowledge and
  understanding
• Everyone up-to-date on current science and
  evidence
• Common language
• Common expectations for interventions for
  nonreassuring FHR patterns and uterine
  hyperstimulation
• Kaiser Permanente Model- Situational
  Awareness in Electronic Fetal Monitoring.
       Situational Briefing Model

    S-B-A-R
•   Situation
•   Background
•   Assessment
•   Recommendation
                                                        Johnson City Medical Center
SBAR
                                        Obstetric Patients                                     Notes
Report
         Identify yourself and where you are calling from
         Patient’s name and reason for report
         Patient was admitted for:________________________
         I am concerned about (examples):
                   oFHR
                   oContraction Pattern
 S                 oBlood Pressure (give examples)
                   oVaginal Bleeding, etc.




         Gravida____ Para____ @____ weeks gestation
         OB or attending ________________
         Significant medical and obstetrical history includes:_______________________
         Problems with current pregnancy are______
 B       Relate the complaints by the patient and the pain level




         Vital Signs & Significant Findings:
                   oBlood Pressure, TPR
                   oFHR
                   oContraction Pattern
                   oSignificant Lab Values

 A       Intrauterine Resuscitative Measures
         Give your conclusions about the present situation. Words like “might be” or “could
         be” are helpful.
         Clinical Impressions, Concerns



         What I need from you is____________________________
         Be specific about a time frame
         Suggestions for tests/treatments, ie:

 R                 oLabs, Pitocin, Methergine, U/S, mag. Sulfate, etc.
         Clarify all orders, vital sign frequency, under what circumstances to call back
                                     Johnson City Medical Center
SBAR
         Newborn/Pediatric Patients                                                     Notes
Report
         Identify yourself and where you are calling from
         Baby Boy or Girl ____________ and reason for report:
         I am concerned about (examples):
                   oRespirations, SaO2,
                   oTemperature

 S                 oBlood Sugar




         Baby born via []C/S (give reason for__________) []NSVD []Forceps
         []Vacuum Extractor
         Apgar Score, any resuscitative measures
         GBS Status and treatment prior to birth
 B       Significant maternal history
         Relate the physical assessment pertinent to the problem, especially any
         changes


         Vital Signs are:
                   oRespiratory status, presences of grunting, flaring, retractions?
                   oTPR, SaO2
                   oBlood glucose levels, feedings

 A                 oSignificant Lab Values
         Give your conclusions about the present situation. Words like “might be”
         or “could be” are helpful.
         Clinical Impressions, Concerns


         What I need from you is
              ____________________________
         Be specific about a time frame
         Suggestions for tests/treatments:
 R                 oIV, Antibiotics, Chest Xray, CBC, CBG’s, ABG’s, NPO if
                   significant resuscitative efforts, etc.
         Clarify orders, vital sign frequency, under what circumstances to call back
                                 Johnson City Medical Center

SBAR
                             Anesthesia Patients                 Notes
Report
         GOAL: Anesthesiologist and Obstetrician conversation




S        Identify yourself and where you are calling from
         “I’m calling for Dr.___________
             for a [] C/S []Epidural
             ________________________”

         Gravida___ Para___ @___ weeks gestation.
         Reason for C/S:
             __________________________
B        Significant medical and obstetrical history includes
         __________________________
         NPO Status
         Does patient currently have a labor epidural?

         Vital Signs are:
                  oMaternal issues
                  oFetal issues
A        Contraction Pattern, VE, Current labor status
         Significant Lab Values
         Fluid Bolus
         Current status in preparation for OR




R        What time can we be ready for you?
          SBAR Examples

• Examples of other SBAR Tools on ihi.org
  from Seton Medical Center

http://www.ihi.org/IHI/Topics/PerinatalCare/P
  erinatalCareGeneral/EmergingContent/Per
  inatalSBARTools.htm
             Teamwork

• Patient care requires groups to work
  together effectively.
• NASA research found more than 2/3 of
  air crashes involve human error –
  especially failures in teamwork.
• Professional training focuses on
  technical, not interpersonal skills.
  What do we mean by situational
           awareness?
• Aware of the environment around us

• Aware of the situation at hand

• Not „coning of attention‟

• Being aware of the signs around us
  Example- Fairview Southdale
           Hospital
In Situ Training
Simulated Sentinel Events in the hospital
  environment “real time” with all team members
  doing their “real work”.

Each scenario had 5-6 “event sets” or “triggers”
  that were a “distracter” or cause of team stress.


Fairview Southdale Hospital, Minneapolis
 We implemented . . . Fairview

• The pilot for “in Situ Team Simulation” for
  our system in January, 2006.
  – Briefing
  – Simulation from LD room to OR C Section
  – Simulation of Resuscitation of newborn
  – Debriefing
  – Assessment of team dynamics, breakdown in
    communication, process flaws, use of SBAR
     Most promising changes-
       Fairview Southdale
• Recognition of the importance of
  communication:
  – “ I learned so much about how we work”
  – “ It is ALL about communication!”
  – I thought doing a CS in an emergency was just about
    technical skill but there are so many ways that things
    can go wrong with how we get information from one
    department to another!”
• Raised awareness about the hierarchy that
  exists in our unit between MD and RN especially
  that is a barrier from speaking up and stopping
  the show!
For more information on Fairview
  Southdale‟s In Situ Training,
        Please Contact-
          Kristi Miller, CNS
        kmiller5@Fairview.org
             Bill Riley, MD
         riley001@umn.edu
          Stan E Davis, MD
       SDAVIS5@Fairview.org
        Perinatal Trigger Tool
• The use of "triggers," or clues, to identify
  adverse events (AEs) during a manual review of
  a random selected sample of patient charts is an
  effective method for measuring the overall level
  of harm in a health care organization over time.

   The tool defines an adverse event as any
         physical harm to the infant or
    mother, limiting the definition of adverse
    events to physical rather than emotional
                      harm.
• T1 Apgar < 7 at 5 min.         • T12 Hypotension/lethargy
• T2 Admission to NICU and             (Mom e.g. on Magnesium
     >24 hours                         Sulfate)

• T3    Maternal/Neonatal        • T13 Transfer to a Higher
        Transport                      Level of Care, including ICU
•   T4 Terbutaline                     in-house
•   T5 Naloxone                  • T14 Unplanned return to surgery
•   T6 Infant Serum Glucose      • T15 Estimated blood loss > 500 mL
        <50                      • T16 Specialty Consult
•   T7 3rd or 4th Degree         • T17 Administration of oxytocic
        Lacerations                    agents
•   T8 Prolonged decelerations   • T18 Instrumented Delivery
•   T9 Blood Transfusion         • T19 Administration of general
•   T10 Platelet count <50000          anesthetic for delivery
•   T11 Abrupt Medication Stop   • T20 Cord gases ordered
        (e.g. epidural)          • T21 Gestational Diabetes
                                 • T22 Other
 What We Have Learned Thus
Far From the Perinatal Innovation
          Community
      Most Promising Changes
• Empowerment of the          • Department pride in
  nurses in the                 positive changes
  management of               • Orders and protocols
  uterotonic contractions.      evidence-based
• Continuing improvement      • Documentation improved
  within multidisciplinary      in completeness and
  communication.                accuracy
• Raised awareness about      • Approval by OB/GYN
  the hierarchy that exists     department to limit
  in our unit between MD        elective inductions to 39
  and RN especially that is     weeks or greater.
  a barrier from speaking
  up and stopping the
  show.”
 Perinatal Teams- Assumptions
           Challenged
• Hyperstimulation-             • “I know how to give report
  definition and impact to        to a physician”
  fetus                         • “I am already Board
• That everyone described         Certified”
  fetal monitor strips the      • Protocols are not
  same                            necessary for everyone
• That everyone was             • “I‟m too busy to participate”
  utilizing appropriate         • The assumption that 38 ½
  communication                   weeks was “close enough
• I have worked with this         to 39”
  nurse (or MD) for so long     • Providers and nurses need
  that we don‟t need to talk,     separate learning
  we just “know” what to          opportunities.
  do.
 Perinatal Teams- Assumptions
           Challenged
• Bad things don‟t           • “Pit to distress”
  happen to low risk         • “But we‟ve always done
  patients                     it this way!”
• Pitocin is not             • The use of less pitocin
  dangerous, we use it all     will delay active labor
  the time.                    and increase length of
• “the baby will declare       time to delivery.
  itself”…”pitting to        • Increase the pitocin
  distress”                    past the non-reassuring
• If I just work harder or     FHT‟s or
  smarter I won‟t make a       hyperstimulation
  mistake                    • Nurses don‟t question
                               physicians
    Perinatal Teams- Surprises
• The difficulty experienced   • We have had so few
  in engaging physicians in      allegations and the
  the efforts- discouraging      defensibility of our
  due to an overall              documentation
  environment of very          • Fetal birth injury rate has
  supportive medical staff.      dropped so dramatically
• Positive outcomes            • Slow response to
• Improved                       proposed changes
  communications between       • Resistance to SBAR “RN”
  all shareholders               Recommendation
• Everyone can improve         • Abiding to written policies
  their practice                 and standards is very
• Champions may come             person dependent!
  from unexpected places
    Perinatal Teams- Surprises
• Our Model of                 • Concrete objective
  Improvement with PDSA,         results!
  small tests of change,       • More pitocin is not always
  and rapid cycle analysis       better!
  actually works.              • Hyperstimulation is not
• Nurses and physicians          best practice!
  were equally reluctant to    • Compliance with changes
  use the new protocol         • Success breeds success
• Nurse/physician              • Interdisciplinary teams
  definitions of                 can yield greater results
  hyperstimulation and fetal
  status were varied and       • Discovering that “low risk”
  based on past                  patients are the most
  experiences and training       litigated with poor
• A patient really CAN           outcomes
  deliver with less pitocon!   • That the bedside nurses
                                 are being heard

				
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