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MARYLAND PATIENT SAFETY CENTER PERINATAL COLLABORATIVE AND LEARNING NETWORKSecretarys Advisory Committee on Infant MortalityMarch 9, 2012

Raymond L. Cox, MD,MBAI changed the date format, it looks better on documents that are used for external purposes.fFinancial DisclosuresNone

What Do We Want to Accomplish? The aim of the Perinatal Collaborative is to reduce infant and maternal harm through the implementation and integration of systems improvements and team behaviors into maternal-fetal care. The Collaborative is an initiative to test, adopt, and implement evidenced-based improvement strategies in the labor and delivery units of hospitals in Maryland and the District of Columbia.

3Change Package: Tools of ChangeUse of common language (NICHD) in Electronic Fetal Monitoring Training in team coordination, team communication and teamwork behaviorsImprovement in staff performance during high-risk events (simulation)Revision and application of recommended practice guidelinesAugmentation and Elective Induction Bundle (Institute for Healthcare Improvement) complianceEstablish didactic on vacuum extraction4First on the list is effective communication between doctors, midwives and nurses on the interpretation of fetal heart rate monitoring strips. Until 2004, doctors were trained by ACOG in one set of terms and nurses by AWHON in other. In 2004, then National Institute for Child Health Development made recommendations to standardize terms. The industry has been slow to make this happen. Standardizing terminology based on the NICHD recommendations is a requirement of the Collaborative.

Team training or sometimes know as crew resources management has made the airline industry one of the safest in the world. As we saw in culture, how communication happens make an environment safe or risky. Team training takes human factors into account in everyday work and focuses on areas such as team structure, leadership, team cross monitoring, situation awareness, and communication. Some examples of communication techniques to improve effectiveness are SBAR and CUS. Talk about these in light of doctor-nurse communication. We have used the new TeamSTEPPS tools from AHRQ and others. Team training is a requirement of the Collaborative.

Another area of great effort is simulation and critical events team training. This is a process by which a team practices for emergencies like stat C-Sections, shoulder dystocia, maternal hemorrhage, etc. In a recent article by Tim Draycott, simulation was shown to be associated with a significant reduction in 5-minute APGAR scores.

Augmentation and Elective Induction has been the heart of the IHI Perinatal Community. Oxytocin is involved in about 50% of all adverse events and has recently been added to the list of high-alert medications by the Institute for Safe Medication Practices. The bundle is a set of four components that if all done minimize the risk of an adverse event.

What are you saying here?

How Are We Measuring Success?Adverse Outcome IndexAHRQ Hospital Survey on Patient Safety CultureProcess measures related to hospital-specific interventionsImprovement stories

5Improvements- So FarAOI- 36% of the original hospital group improved on all three indicesAOI- 73% improved on at least one scoreSI- 60% Level 1&2 hospitals and 50% Level 3 hospital improved on the Severity IndexLevel 3- 25.6% decrease in NICU admissions>2500 g term babiesAHRQ Culture Survey- improvement in 9 of 12 dimensionsSince January 2009, elective inductions less than 39 weeks without a medical indication have decreased by 70%iS THIS INTENTIONAL?Are We Saving Money Yet?152 fewer term babies to NICUEstimated average savings/patient = $991-$2,105Total estimated savings = $150,632- $319,960

Neonatal Learning NetworkNeonatal/Perinatal Learning NetworkGolden Hour/ Resuscitation and StabilizationTeamwork and Communication/ Follow up to Referral PhysicianCLABSI/HAI

Activated discharge planning for mom, baby

Successful Change StrategyCreate Burning PlatformEngage LeadershipBorrow ShamelesslyEstablish Non-Negotiable Mutual RespectPractice Relentless PersistenceCreate Ongoing Opportunity for DiscussionConstantly Measure and AdjustExcellence in ObstetricsA Multi-Site AHRQ Demonstration ProjectJames Bell AssociatesSite VisitJuly 6 & 7, 2011

13CollaboratorsBrandeis UniversitySystem OfficeResourcesAHRQSacred Heart Hospital on the Emerald CoastSt. John Hospital & Medical CenterSt. Vincents Health SystemColumbia St. MarysSaint Agnes Hospital14Brandeis University Data methodology, data analysis, team members linked with sub-groupsEthnoworks Qualitative Report and ethnographyNew York Judicial System and Fairview Hospital Lessons learned, TeamSTEPPS trainingUniversity of Wisconsin Madison Human factors research, Systems Engineering Initiative for Patient Safety (SEIPS) CenterCenters for Medicaid & Medicare ServicesAgency for Healthcare Research & Quality

14WhyHealing without Harm: A Multi-Site Demonstration Project to Develop New Models for Medical Liability and Improve Patient SafetyHypothesis 12345WhatDecrease in shoulder dystocia injury rates and infant harm when the bundle is introduced Change in delays of treatment when fetal distress occurs and an increase in cesarean section effectiveness (necessity and timeliness) when the protocol guidelines are followedReduction in the frequency and severity (settlement amount) of claims when full disclosure is implementedIncrease in reporting of Serious Safety Events when 5 elements of High Reliability have been adoptedDecrease in all birth trauma events and rates15Healing without Harm Year OneMajor Milestones593 nurses/physicians trained on multiple interventions4280+ mothers consented between January-July 2011 Average consent enrollment rate at five sites 88% Race/ethnicity breakdown of consented mothers59% white 20% black9% Hispanic2% Asian/Pacific2% Other7% Unknown

16Healing without Harm Year One Interventions for Clinical & Cultural Change

Jose S. PerezPerez on Medicine