clinical project reduction of primary post-partum haemorrhage filepost-partum haemorrhage (pph) is...

Clinical Project Reduction of Primary Post-Partum Haemorrhage

Clinical Services - Best Project Award 2017 2

Content

Main Information --------------------------------------------------------------------------------------- 3

The first criteria: Study and define project objectives ------------------------------------------- 4

The second criteria: Project Team ----------------------------------------------------------------- 18

The third criteria: Resource Management and Control --------------------------------------- 21

The fourth criteria: Risk Management and Project sustainability --------------------------- 24

The fifth criteria: Project execution --------------------------------------------------------------- 27

The sixth criteria: Results --------------------------------------------------------------------------- 33


A summary of the project and its reasons Post-partum haemorrhage (PPH) is one of the leading causes of maternal death globally. Corniche Hospital runs a high risk obstetric service as the tertiary provider in Abu Dhabi. In 2016 the rate of PPH, greater than 1500 mls, was persistently above the agreed SEHA benchmark of 1% of all deliveries. Following literature review and service line agreement the benchmark was altered to 1.5% of deliveries above 2000 mls. However our focused mission at Corniche was to ensure that there were no avoidable PPH cases and any PPH was minimised to avoid morbidity. The objectives of the project are:

Reduce the rate of massive PPH ≥ 1500 mls to below 1.5% (as a stretch goal)

Analyse and redesign processes and procedures to facilitate clinical management of PPH

Update policies and procedures to reflect best practice Ensure sustainability of achieved results by maintaining a standardised approach to management and reporting of PPH Department: Labour and Delivery Suite

Project Manager: Jill Henry (LDS Unit Manager)

Main members of the project team

Name Role Mobile Email

Jill Henry LDS Unit Manager 4805062230 [email protected]

Provvidenza Stefanoni

Charge Midwife 0501390791 [email protected]

Anu Ravi Staff Midwife 0505629244 [email protected]

Sumitha Zachariah Staff Midwife 0505806752 [email protected]

Maria Thomas Staff Midwife 0569538429 [email protected]

Eman Mashal Staff Midwife 0543330525 [email protected]

Jane Kelly Director of Quality 0506121951 [email protected]

Rita Arslanian Performance Management Officer

0562125764 [email protected]

Dr. Saleema Wani Chair of Obstetrics 0506227139 [email protected]

Dr. Margaret Blott Chair of Academic Affairs 0506129184 [email protected]

Dr. Tarek Ansari Chief of Anesthesia 0561173994 [email protected]

Dr. Soha Said Consultant Obstetrician 0553528876 [email protected]

Dr. Priya Sequeira Specialist Physician 0501586885 [email protected]

01 / 04 / 2017 Project Starting Date

The person who can be contacted in with any issues related to the project submission :

Name Telephone Mobile Email

Jill Henry + 971 (2) 696 5578 + 971 (50) 622 3048 [email protected]


The First Criteria: Study and Define Project Objective

Introduction

1. Identify and set goals and project document

Post-partum haemorrhage (PPH) is one of the leading causes of maternal death globally. Corniche Hospital runs a high risk obstetric service as the tertiary provider in Abu Dhabi. Our focused mission at Corniche was to ensure that there were no avoidable PPH cases and any PPH was minimised to avoid morbidity. Problem statement In 2016 the rate of PPH greater than 1500 mls was persistently above the agreed

SEHA benchmark of 1% of all deliveries. Following literature review and service line

agreement the benchmark was altered to 1.5% of deliveries above 2000 mls.

Project Objectives Reduce the rate of massive PPH ≥ 1500 mls to below 1.5%

Review of policies and procedures to reflect best practice


Ensure sustainability of achieved results by maintaining a standardised approach to

management and reporting of PPH

Project Document During the initiating phase all the documents needed to define the quality improvement project were

created including:

Quality Improvement Project Charter was submitted to the Quality Department for

registration. The Quality Department has a robust system to register all QIPs in order to

ensure commitment to all 5 phases of project management, as well as:

o Ensure alignment with the hospitals and Abu Dhabi Health Services Company SEHA’s

strategic priorities, this project was aligned with the strategic priority to ensure

quality outcomes meet or exceed benchmark performance.

o Registration and tracking of all QIPs

o Evaluate the progress of the QIP and hold the members accountable in their annual

performance evaluation (I-perform)

o Allow the Quality Department to have oversight of the project and to follow-up the

achievement and sustainability of planned objectives.

Data collection and analysis tools for all patients who had a blood loss


≥ 1500 mls within 24 hours of delivery.

The team in Labour and Delivery Suite (LDS) designed a survey to determine if any delay in

medication administration was contributing to an increase in blood loss. The survey called

“Snapshot Review of Third Stage Medications” was conducted before the implementation of

the changes, and repeated throughout the study.

A variety of communication tools were designed and used including the minutes of meeting

of the project team; “Risk Assessment for PPH” to standardize the interpretation of risk for all

clinicians in labour ward; regular presentations of the survey findings to the project team and

LDS team; update references material and policy to reflect the actual consumables used to

quantify blood loss.

Team assessment surveys.

2. Project Plan and Execution Stages of Implementation

Initiation Phase The scope of service of the project is to decrease post-partum hemorrhage in

all modes of delivery.

The preliminary idea of the project started in 2016, it was managed by the LDS

Buddy Group, but the approach was not structured and it failed to meet the

objectives. In 2017 to ensure a structured approach and the success of the

project, the LDS Unit Manager identified a new Buddy Group lead to drive the

project, key stakeholders and involved the Quality Department.

Stakeholders were identified; managing stakeholders is a key component of

successful project management and should never be ignored. Proper

stakeholder management can be used to gain support for a project and

anticipate resistance, conflict, or competing objectives.

Planning Phase Brainstorming sessions by the Taskforce clearly indicated the need for

individualised assessment of massive PPHs and an accurate data collection tool.

In addition to this there was a need to perform a Risk Assessment for PPH on

every admission to the unit. It was key to involve all clinicians responsible for

delivering babies on LDS, this included midwives and obstetricians. The PPH

taskforce group put together during the initiation phase communicated the

objectives to these clinicians and laid out clear guidelines of how the project


Stakeholder Management

Effectively managing stakeholders is a key component of successful project management and should

never be ignored. Proper stakeholder management can be used to gain support for a project and

anticipate resistance, conflict, or competing objectives among the project’s stakeholders. It also gives

the project team a clear understanding of what the stakeholder’s needs and expectations are. This is

done at the initiation stage to allow the team to consider those expectations while planning the

project’s objectives and deliverables.

As part of the requirements to submit the QIP Proposals, project managers were required to do

stakeholder identification and have them included in their communication plan.

Identify Stakeholders The Quality Department led a brainstorming session with the LDS Buddy Group and unit manager

where stakeholders were identified as:

was to proceed. Regular reassessment of findings and updates were essential

and to be ongoing. Audits on administration of uterotonics were to be carried

out to identify any gaps in the process.

Implementation

Phase

A risk assessment tool for PPH and data collection sheets for cases of PPH was

drafted and education of clinicians given. The multidisciplinary daily shift

handover sessions were key to ensuring education and compliance of the

changes was being adhered to. Observational audits on compliance for

administering uterotonics with delivery of the anterior shoulder were also

carried out.

Monitoring and

Controlling Phase

Regular taskforce meetings were held to review cases of PPH and audit findings,

identifying any gaps in management. From this analysis the taskforce were able

to identify areas of improvement in the process which would be incorporated

into updating policy.

Closing Phase A third audit of uterotonic administration is to be completed by the end of

November. A change of uterotonic medication to carbetocin is underway. The

taskforce aims to continue its work on this issue into 2018.


Different categories of stakeholders were identified:

Patient was identified as the key stakeholder since they are directly affected by the success of the

failure of the project. Any positive or negative outcomes from the project will have a direct impact

upon them.

All clinicians providing care on LDS and OT are key stakeholders because they are planning, providing,

and managing the care. Having their buy-in and commitment guarantees the success of the project.

The clinicians are comprised of two groups:

The midwives who were updated and educated about the objectives of the project

and progress. To ensure their full engagement the PPH rate became a departmental

performance objective in their annual

I-perform.

The physicians and anesthetists were a major stakeholder therefore having their full

commitment was very critical to the project’s success. By having the chairs and chiefs

as part of the project team from conception they were fully engaged with the project.

Operating Theatre/ HDU: For continuity of care, patients with uncontrolled massive bleeding are

usually transferred to these units for continued management. Maintaining an open communication

between these units and LDS is essential for management of information related to the project.

Clinics: Clear communication of the “Plan of Care” of a certain category of patients who require a

specific third stage management might prevent massive blood loss.

Pharmacy: to redefine the management process of third stage medication administration, and

properly manage stock levels.

Post natal units: Primary PPH is defined as massive bleeding within 24 hours of delivery which is why

post natal units are key in documenting and reporting further blood loss.


Quality Department: was facilitating the project as a part of the team, but as stakeholders the main

role is to provide LDS with timely data, update policies as required, and assign incident reports for

review.

Administration: approve the project and provide high level support if needed.

Key Stakeholders

They key stakeholders who have the most influence over the project are the physicians and the

midwives in LDS and OT. To avoid any resistance to change their buy-in and commitment was

essential. The project team provided regular updates and open communication to manage them

closely throughout the project’s lifecycle.

Stakeholder Analysis

Here, the Stakeholder Management Strategy describes how the project team analysed its list of

identified stakeholders. This discussion included how stakeholders will be categorised or grouped as

well as the level of impact they may have based on their power, influence, and involvement in the

project. There are several tools and techniques that can be used to help quantify stakeholders. A

description of these tools and techniques should also be included in this section.

Department Position Interest (1 – 5)

Power (1 – 5)

Prioritization

A Obstetrics Chair of Obstetrics 5 5 25

B Anaesthesia Chief of Anaesthesia 4 5 20

C Academic Affairs Chief of Academic Affairs 4 5 20

D Obstetric Obstetric Lead for LDS 5 4 20

E Operating Theatre Charge Nurse 2 2 4

F Labour and Delivery Suite

All midwives 3 5 15

G Quality Department Director of Quality 4 3 12

H Pharmacy Senior Clinical Pharmacist 1 3 3

I HDU Unit Manager 1 1 1

J Clinics Unit Manager 1 3 3

K Post natal Units Unit Manager 1 3 3

L Administration Chief Nursing Officer Assistant Director of Nursing

1 5 5


The stakeholder analysis matrix was used to capture stakeholder concerns, level of involvement, and

management strategy based on the stakeholder analysis and power/interest matrix above. The

stakeholder analysis matrix was reviewed throughout the project’s duration in order to capture any

new concerns or stakeholder management strategy efforts.

Strategy Quadrant Concern Stakeholder

Engaging them at the conception

of the project as team members

Manage Closely

Manage Closely

Manage Closely

Manage Closely

Obstetrics A

Anaesthesia B

Academic Affairs C

Obstetric D

Communicate the project updates

by circulating the minutes

Keep Informed Operating Theatre E

Communicate updates

Recognition through appraisal

system

Keep Satisfied Labour and Delivery

Suite

F

Director of Quality and

Performance Management Officer

as project team members

Keep Informed Quality Department G

Face to face meeting and email

communication when required

Keep Informed Pharmacy H

ga et w ga taae ec f ec eca

ne e a e cai

Monitor HDU I

Face to face meeting and email

communication when required

Keep Informed Clinics J

Post natal Units K

Administration L

3. Develop an organised and comprehensive plan for internal and external communication Meetings are held monthly at a minimum and all meeting minutes are kept as a soft copy and

circulated to the team members with the assigned tasks. Review of minutes with standing agenda

items and progress on assigned tasks are carried out at every meeting.

Situation, Background, Assessment, and Recommendation (SBAR) communication is the tool used at

multidisciplinary handover meetings every morning to communicate internally all PPHs within the

last 24 hours. The patient MRN is used to communicate this information and the meetings are held

in a private setting involving only the concerned clinical team to ensure patient confidentiality.


The progress of the project is discussed as a Buddy Group feedback standing item at the LDS monthly

meetings.

All new changes to the process are communicated to the LDS team by developing tools and

communicating the changes verbally through buddy group education.

To avoid communication constraints and communication based conflicts the following meeting date

and time are decided at the end of each meeting with team consensus. All minutes are circulated to

the members; an email group was created including all the team members called “PPH Taskforce” so

that none of the team members are missed out from any communication. There were different

channels of communication throughout the project:

1. Communication related to assigned actions are reviewed at every meeting and circulated by

email to all team members.

2. Progress on individual tasks and action items is relayed back by email and discussion at the

next meeting.

Communication

Type

Objective of

Communication

Frequency Audience Owner Deliverable Medium/ Format

Kickoff Meeting Introduce the

project team

and the project.

Review project

objectives and

management

approach.

Once Project

Sponsor

Project Team

Stakeholders

Project

Manager

Agenda

Meeting

Minutes

Soft copy archived

on project

SharePoint site

and project web

site

Regular

meetings

Follow on the

tasks and

review results to

plan for future

actions

Minimum

monthly

Project Team Project

Manager

Agenda

Meeting

Minutes

Adhoc meetings Communicate

project

requirements

with the

stakeholders in

the “Keep

Informed” grid

Ad Hoc Other units Project

Manager

Email Email

communication


4. Develop a quality assurance plan (Continuous Quality Improvement Plan

The main purpose of the Project Quality Management Plan for the QIPs is to document necessary

information required to effectively manage project quality from project planning to delivery. It

defines the projects quality policies, procedures, criteria and areas of application, roles, and

responsibilities.

In the first section the plan focuses on identifying and clearly describing the primary roles and

responsibilities of the project staff as it relates to the practice of Project Quality Management.

Indicates responsibilities for activities such as mentoring or coaching, auditing work products,

auditing processes and participating in project reviews.

Name Role Quality Responsibility

Jill Henry Project Manager Quality mentoring & coaching

Valentina Stefanoni Team Lead Quality audits; Data collection

Anu Ravi Team member Quality audits; Data collection

Eman Mashal Team member Quality audits; Data collection

Sumitha Zachariah Team member Quality audits; Data collection

Maria Thomas Team member Quality audits; Data collection

Rita Arslanian Project Coordinator Meeting minutes ; Compliance with project

charter

Dr. Saleema Wani Team member Subject matter expert; Ensure obstetric support

Dr. Margaret Blott Team member Subject matter expert

Survey Findings Communicate

survey findings

When data is

available - at

unit meeting

LDS Midwives Project

Manager

Power point

presentation

Soft copy archived

on project

SharePoint site

and project web

site

Quality Board

Project Status /

Progress

Communicate

project progress

and changes in

KPI scores

Monthly at

unit

meeting


Dr. Tarek Ansari

Dr. Soha Said

Dr. Priya Sequeria

Dr. Reem Taha

In the second section the plan focuses on listing and defining the data requirements and the quality

tools that will be used to measure the quality of the project and conformance with the defined

indicators.

Tools Description

Literature review http://www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-

performance-and-governance-score-card

Intramuscular Oxytocics: A Comparison Study of Intramuscular Carbetocin, Syntocinon and Syntometrine for the Third Stage of Labour Following Vaginal Birth (IMOX) North Bristol NHS Trust Carbetocin for the Prevention of Postpartum Hemorrhage D. Cordovani, J. C. A. Carvalho, M.

Boucher and D. Farine

Paerto Diagram Survey was conducted regarding the time of administration of the Uterotonics and to identify

why they were not given with anterior shoulder. The reasons were clustered by categories and

action plans were implemented to address the main 2 categories.

Learn from experience of

other SEHA BEs

Other SEHA BE Labour & Delivery Units were approached to identify their third stage

medication management. A uterotonic Carbetocin was the medication of choice by the

majority. Unfortunately they could not provide the data surrounding the subsequent

implementation of the medication.

Lessons learned from previous projects

Brainstorming session with the team who tried to implement the project last year to identify

the pitfalls

Obstetric Drills Multidisciplinary unit based obstetric emergency drills incorporating management of PPH were

increased on LDS. Scores improved accordingly.

Education An audio visual teaching tool on the management of PPH was compiled by a group of LDS

midwives. This was presented at the multidisciplinary morning meeting and is available for staff

reference on the Intranet.

http://www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card

http://www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card


This graph

demonstrates

the outstanding

improvement on

how clinical staff

performed

during unit based

Obstetric PPH

drills

The team conducted a brainstorming session and detailed analysis of the primary reasons leading

to high PPH, delay in administering a uterotonic was identified as a possible leading cause.

Therefore an audit was conducted as a Snapshot Review of Third Stage Medication for 70 vaginal

deliveries (22%) in April to confirm the assumption and to identify the reasons for the delay.

Observational assessment was done in April and it indicated that 63% of Uterotonics were given

appropriately, whereas 37% were not. A breakdown analysis of the 37% was done and indicated

that the primary reason not administering the uterotonics appropriately was PPID (47%) (Positive

Patient Identification) this is an automated medication dispensing system (Pyxis) and the process

time is longer than the timeframe for administering the medication. Staff being busy with other

tasks (30%) was the second most common reason (see the table below). The LDS management

raised awareness of the importance of prioritising tasks properly and simultaneously discussed with

pharmacy the feasibility of overriding the PPID for uterotonics and that they be classified as

emergency medication. To assess and refine, the survey was repeated after 4 months in August

observing 78 vaginal deliveries (23%), unfortunately the results showed a decrease in compliance

to 58% and PPID remained the main contributing factor but it decreased to 23%, and the second

contributing factor was still other tasks but it also decreased to 16%. To further assess and refine

ongoing education the audit will be repeated in November.


A. Definition and measurement of Quality


B. Continuous Improvement – RADAR

The EFQM RADAR logic is adopted by Corniche Hospital as the roadmap to continuous quality

improvement and to assessing the maturity of the approaches implemented and the excellence of

the results achieved.

C. Sustainability

Sustainability is a part of the Assess and Refine phase of the RADAR and it is conducted throughout

the life cycle of the project. Sustainability is also related to how well the project is closed and handed

over to the Operations, as soon as that occurs it is the responsibility of the Unit/ Department Manager

to continue monitoring and keeping track of the performance indicators. As a part of its oversight to

the projects the Quality Department will ask the Quality Ambassadors to discuss those KPIs in Quality

Ambassadors Meeting on a Quarterly Basis. The Quality Department might conduct random audits

and look for track of monitors for closed projects during the tracer activities.

• Stakeholder involvement

• Communication and education

• Assessment through survey

• Indidual case reviews

• Retrospective analysis of PPH cases

• Analysis of individual PPH cases in multudisciplinary teams

• Detailed assessment of the management of PPH

• Identification of the root causes

•

• In 2016, the rate of PPH ≥2000𝑚𝑙𝑠 𝑤𝑎𝑠 1.15%,𝑎𝑛𝑑 PPH ≥

1500𝑚𝑙𝑠 𝑤𝑎𝑠 2.55%,

•Reduce the rate of massive PPH ≥ 1,500 ml to below 1.5% (as a

stretch goal)

ResultsHow do you need to

Approach the problem to get the

results you need

DeployAssess

and Refine


The Second Criteria: Project Team

Manage and Lead Project Team

The foundation of the team was the Midwifery Buddy group, which was selected specifically because

of the team’s high interest and self-motivation to move the project forward and guarantee its

success. The project objectives are linked to the mid-year and annual performance appraisal of the

midwives to hold them accountable and recognise their efforts simultaneously.

The physician leads were selected to be on the team because of their expert opinion and authority

to adapt, implement policy, and cascade information about the project to the physicians and

safeguard the sustainability of outcomes. As for the quality team, their involvement in the team was

crucial to coordinate the project and keep it on track.

To avoid conflict due to vagueness of roles which might result in delays of completion of tasks, all

roles and responsibilities were assigned clearly for all team members. At every meeting the tasks

were discussed and reviewed. The following responsibility assignment matrix RACI was used to shows

the relationship between project tasks and team members. Any proposed changes to project

responsibilities was reviewed and approved by the project manager and the Corniche Leadership

Team member owning the project.

Task List Jill Henry Valentina and Buddy

Group

Dr. Saleema Wani

Quality Department

(Rita Arslanian Jane Kelly)

Rest of the team

Risk Assessment Plan R R I A I

Quality Management Plan R R I A I

Data collection and analysis tool

AI R CI R CI

Developing forms to discuss and hand over all blood loss cases in a shift

AC R RC R CI

Develop survey tool, conduct and analyze the survey – Snapshot Review of Third Stage Medication

AC R I I I


Key: R – Responsible for completing the work A – Accountable for ensuring task completion/sign off C – Consulted before any decisions are made I – Informed of when an action/decision has been made

The main challenge was engaging the team from theater and committing them to the project as team

members. Out of the 11 meeting there was only 2 meetings with OT nursing representation, after

the 8th meeting the Chair of Anesthesia joined the project team representing anesthesia and OT.

Since the roles and responsibilities were very clearly defined and tracked there was very little room

for conflict.

The efforts of the buddy group are directly linked to their annual appraisal, and the team receives

thank you cards in recognition of their commitment to the project.

Risk assessment reference tool

A R C I CI

Dry weight consumable reference tool

A R I I I

Create PPH taskforce mailing list and shared drive

CI CI CI RA CI

Overriding PPID for uterotonic medication administration

AR I I I I

2016 and 2017 data analysis I I RI AR I

Clarify definition of Post-Partum Hemorrhage and calculation criteria

I I RC ARI CI

Coordinate with all post-natal units and HDU to standardize quantitative blood loss measurement

AR I I I I

Coordinate with all post-natal units and HDU to report back blood losses in the units

AR I I I I

Literature review I R R I R


The Third Criteria: Resource Management and Control

1. Manage financial resources related to the project

The final recommendation was to change the uterotonic medication to a more expensive

alternative, Carbetocin 100mcg which is already on SEHA Formulary.

Clinical time, stationary and meeting room space were the only notable expenditures

2. Manage and direct knowledge resources and identify a systematic and comprehensive plan

Taskforce meetings were minuted and circulated to the PPH Taskforce group using the

collective contact group address which had been set up at the onset of the project. Minutes

detailed action responsibilities and timelines. All action points were reviewed at each meeting

and updates shared. The group contact address was used to share research articles and any

new developments. Laterally the shared drive was accessible for referencing each PPH case

dating back to January

3. Manage and direct suppliers

Name of group member and

designation

Reason chosen

Jill Henry - LDS Unit Manager LDS Unit Manager and the department’s performance directly impacts the PPH rate

Valentina and Buddy Group – LDS

Buddy Group

LDS Buddy Group and driver of change to improve the performance which directly impacts the PPH rate

Jane Kelly – Director of Quality Quality department measures the performance

Rita Arslanian – Performance

Management Officer

Coordinator for the project

Chairs and Chiefs of Departments

and Consultants

The physicians performance directly impacts the PPH rate and for expert

advice


Suppliers of Carbetocin have been contacted by our pharmacy to confirm adequate ongoing

availability for our needs when we transfer to this uterotonic. Supplies are sufficient and a

review of stocks of current uterotonics have taken place to identify a timeframe for the

crossover

4. Assure optimum Resources use

Actual Benefits (Effectiveness) Actual Costs

1. Positive outcomes Reduction in PPH rates

Reduced resources utilization (cost, manpower, and physician

resources)

PPH rates with will aligned with international best practices as a center

of excellence for high risk obstetric care

2. Resources Expanded Cost of new medication Cost of stationary Cost of clinical time

3. Negative outcomes avoided Short/long term negative outcomes avoided Increase of patients’ complaints due to complex process in discharging

the patients.

4. Negative outcomes

Patient identification process

Project Dependent Project Independent Observed Impacts

X Increased awareness throughout the disciplines

X Increased staff engagement and interest to improve

reduce the rate of PPH

X Updated knowledge on the latest clinical trials

X Improved patient safety

Enabling Factors Hindering Factors

All stakeholders were highly engaged and involved. The project plan and implementation was well structured. Effective communication by regular updates, feedback, and meetings.

Difficulty getting information related to PPH medication and

management from other SEHA facilities.

Lengthy internal process to introduce a change in medication

Lengthy process to override PPID for third stage medication


The Fourth Criteria: Risk Management and Project Sustainability

Risk management is essential to effectively manage a project, and describes what is needed before

risk management can begin. Risk management should be done at the beginning of the project,

during the mid-project review, if there are any changes in scope, and once the project is closed

and handed over to operations.

Risk Identification

At the initiation phase of the project, the new Buddy Group responsible for the

implementation of the project had a structured risk assessment meeting with a

representative from the previous project group and subject matter expert.

The “Risk Assessment” meeting was minuted and a risk assessment tool was used to identify

the occurrence, severity, and detection of each risk. For every detected risk the team voted

for the type of strategy to address the risk (accept, mitigate or avoid it), and devised

strategy to address each risk.

The risks were divided into three main categories:

a. Historical review of similar

b. Risks which can delay or hinder the project

c. Risks which are an outcome of the project and can have a negative impact on the

operations


Risk Qualification and Prioritization

Risk Identified Risk Type Occurrence Severity Detection Priority Strategy to address the risk

Less

on

s Le

arn

ed

fro

m p

revi

ou

s p

roje

ct

No robust planning Management related

1 4 1 4 Avoid

No ownership of the project, the project was led by a buddy group and then handed over to a lead who was not a part of the initial group

Management related

3 5 1 15 Avoid

No delegation Management related

3 5 1 15 Avoid

No clarity in roles and responsibilities

Management related

3 5 1 15 Avoid

Lack of clear communication

Management related

3 5 1 15 Avoid

No commitment from the subject matter experts

Physician related

4 5 3 60 Mitigate

Changes were not supported by the LDS education department ( Staff education)

Midwife related

2 5 1 10 Avoid

Lack of buy in of the key stakeholders

Physician related

3 5 1 15 Avoid

Was not linked to individual performance appraisal as a motivating factor

Midwife related

3 5 1 15 Avoid

Pro

ject

Co

mp

leti

on

Ris

ks

Poor attendance at the regular meetings which delay follow-up on completion of planned actions and hinders communication

Management related

4 5 1 20 Avoid

Response rate to the survey

Midwife related

3 5 2 30 Avoid

LDS staff compliance and commitment

Midwife related

3 5 1 15 Avoid

OR staff commitment and buy-in

Physician related

4 5 3 60 Avoid


Post- natal ward commitment and buy-in

Unit Managers 5 5 1 25 Avoid

Physician commitment and buy-in

Physician related

5 5 1 25 Avoid

Challenges in communication with medical team for issues related to the project (physicians)

Physician related

5 5 1 25 Mitigate

Pro

ject

Ou

tco

me

Ris

ks

Medication identification errors due to non- PPID of uterotonics

Midwife related

1 5 5 25 Avoid

Misinterpretation of “Risk Assessment for PPH Tool”

Midwife related Physician related

1 3 3 9 Avoid

Risk Monitoring

The “Risk Assessment” meeting was recoded and a risk assessment tool was used to identify

the occurrence, severity, and detection of each risk. For every detected risk the team voted

for the type of strategy to address the risk (accept, mitigate or avoid it), and devised strategy

to address them.

The risks with the highest scores to the project schedule were given high priority and

addressed at the planning phase of the project and all risks were monitored and reviewed at

the monthly meetings.


Risk Mitigation and Avoidance

Risk Identified Strategy description

Less

on

s Le

arn

ed

fro

m p

revi

ou

s p

roje

ct

No robust planning Proper planning of the project

No ownership of the project, the project was led by a buddy group and then handed over to a lead who was not a part of the initial group

Clear communication and assignment of roles and responsibilities

No delegation Clear communication and assignment of roles and responsibilities

No clarity in roles and responsibilities Clear communication and assignment of roles and responsibilities

Lack of clear communication Develop a clear project communication plan, regular meetings and minutes of meeting

No commitment from the subject matter experts Engage the chief and chairs of department as subject matter experts and serve as a communication channel with the physicians


The buddy group is fully accountable to ensure that all LDS midwives are well informed and educated - monitoring outcomes (SIs, quantifying blood loss, relevant paper work is filled up)

Lack of buy in of the key stakeholders Involving the stakeholders as project team members, and linking the success of the project to their performance appraisal


Linking the success of the project to their performance appraisal

Pro

ject

Co

mp

leti

on

Ris

ks

Poor attendance at the regular meetings which delay follow-up on completion of planned actions and hinders communication

To have structured meetings with minutes, link it to individual performance, team availability and consensus on meeting dates

Response rate to the survey Midwife engagement, feedback, and communication

LDS staff compliance and commitment Linking the success of the project to their performance appraisal Midwife engagement, feedback, and communication

OR staff commitment and buy-in Involving them as project team members.

Post- natal ward commitment and buy-in One to one meetings with unit managers, email communication, plan a stakeholders meeting

Physician commitment and buy-in Engage the chief and chairs of department as subject matter experts and serve as a communication channel with the physicians


Challenges in communication with medical team for issues related to the project (physicians)

Communicate through Chiefs and chairs and hold the chiefs and chairs accountable

Pro

ject

Ou

tco

me

Ris

ks

Medication identification errors due to non- PPID of uterotonics

Reinforce medication and patient identification policy

Misinterpretation of “Risk Assessment for PPH Tool” Review of the tool and education


The Fifth Criteria: Project Execution

Develop a system for Managing Records and project activities and assure document support and

operation execution, control, review, update and develop solutions and preventive and corrective

action

Individual PPH data collection sheet

This form was designed at the onset of the project in an attempt to capture individualised cases

of PPH >1500mls. The form was used for all modes of delivery in accordance with KPI criteria.

Education of the multidisciplinary team was provided, stakeholders included. This form became

a part of the LDS based multidisciplinary team handover. If forms had not been completed or

submitted then the primary caregiver was approached and requested to do so. This change took

time to achieve full compliance however it is now embedded in practice.


Monthly PPH data collection sheet.

From the individualised form the data was transferred to the monthly data collection sheet

above. This was managed by the Buddy Group and used for breakdown and comparison analysis

which was fed back to the Taskforce meetings. From October we have refined the process

further and now collect all information on an excel spreadsheet.

Project closure

The PPH Taskforce and Buddy Group have proved so successful with their focus on this topic

that the plan is to continue into 2018. Risk assessment has proved a valuable tool and prompted

the clinicians to review the patients’ risk of PPH on arrival to the unit. This is an ongoing

assessment during labour and risk factors may and can change dependent on situation. This

ultimately impacts management of the case in an individualised approach. We hope to develop

this tool as we collate further data.

Individual Data collection tool has proved invaluable and will continue. We are happy with the

layout and now have 100% compliance in completing the form from the primary clinicians.

An excel spreadsheet will help us review our data collection and with the help of our Quality

Department we hope to develop this further as the project matures.

The Taskforce feel that it is essential to continue with regular meetings, these will be held a

minimum of once per month.

The approval and introduction of Carbetocin 100mcg is imminent and will require a committed

analysis following implementation. The clinical and financial benefit will be scrutinized, which

will be carried out over a three month period to assess the clinical impact.

Policy changes have been drafted in line with the above mentioned changes and will be finalised

following the change over to carbetocin.


Quantitative blood loss calculation is a robust process on both LDS and OT and shall continue.

The reporting system of PPH is robust and shall continue

Lessons Learned From Previous Projects

No robust planning

No ownership of the project, the project was led by a buddy group and then handed over to

a lead who was not a part of the initial group

No delegation

No clarity in roles and responsibilities

Lack of clear communication

No commitment from the subject matter experts


Lack of buy in of the key stakeholders


Lessons Learnt from the current Project

Process Improvement Recommendations:

Full Taskforce attendance at meetings

Action issues completed within timeframe

Audit compliance

Category Issue Problem/Success Impact Recommendation

Stakeholder Buy in Not all stakeholders fully committed to project

Failure to attend Taskforce meetings and provide valuable input

Moderate – loss of valuable knowledge

Ensure each area chooses a committed and motivated individual

Communication Failure to complete individualised data collection form

Initially when the PPH data collection tool was implemented not all cases were reported

High – cases not reported back to multidisciplinary team for review

Increased awareness through SBAR

Audit of third stage medication administration

Length of time to collect Although midwives were aware of the audit many did not complete the form

Moderate – caused a delay in analyzing contributing factors

As a new patient arrives in the department the form is automatically handed into the delivery room by the ward clerk

Research Review Too many members undertook to do this

Delay in feeding back research findings to Taskforce

High - Delay in planning and decision making

Nominate and delegate appropriately


Post Project Review

Transition to Operations:

The taskforce and Buddy Group shall continue to develop the project into 2018. Both groups wish

to retain the same member group and as we have a variety of key people in the Taskforce

membership shall remain unchanged. The advantage of this will allow the transition into the coming

year to be unhindered with all members aware of ‘where we are at’ and the progress that has been

made.

Planned Deliverable Actual Deliverable Summary

Reduce the rate of massive PPH ≥ 1500 mls to below 1.5%

We have successfully categorised and

compared risk factors and causes. This vital

step has enabled us to analyse the way

forward to further reduce our PPH rates.

Our approach to PPH is standardised and

embedded. Awareness amongst clinicians

is extremely high.

We are reassured that by implementing changes in management through our project there has not been an increase in rates. The month to month results have not reduced as significantly as we had hoped however we appreciate that in this high risk tertiary setting we have unique challenges. Our mission as a Taskforce is to continue to combine our expertise in obstetrics and explore all avenues for continued improvement.


Increased education, obstetric drills scenarios and case reviews have allowed us ample scope to redesign and analyse our processes and procedures processes

We are satisfied with the clinical multidisciplinary approach to management of PPH. The teamwork is coordinated and follows policy

Update policies and procedures to reflect best practice

Policies updated to reflect current practice Policies and procedures will need further update following change of uterotonic. Research has also highlighted there may be a need to change the order of our PPH medications.


The Sixth Criteria: Results

Project KPIs and results

Project Effect Indicators

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

% P

PH

% PPH ≥ 2,000 ml (2016 - 2017)

2016 2017


This graph demonstrates a breakdown of Risk Assessment for all

women admitted to LDS that subsequently had a vaginal delivery

and PPH of ≥1500mls

This graph demonstrates a breakdown of causes in the above population of PPH.

This graph demonstrates a breakdown of the group identified in labour as low risk and their mode of vaginal delivery.

This graph demonstrates a breakdown of the group identified in labour as low risk and the cause of PPH (LSCS not included as this will always be due to atony).

This graph demonstrates a breakdown of the group

identified in labour as low risk that had a Cesarean

delivery.


Project Team Indicators:

Project Team Evaluation; from the 13 evaluation forms we received 11 back

Strongly agree

Agree Neutral Disagree Strongly disagree

The project objectives were clear to all team members

11

The team had adequate skill mix and member resources to complete the tasks and achieve the objectives

11

The meetings were well attended by all the team members

4 3 3 1

The project manager was approachable

11

The meetings were run efficiently 8 3

Tasks were fairly divided among tam members

6 5

The team worked well together 9 2

.

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