Innovation in Perinatal Care: Learnings from Phase II of the PremierIHI Perinatal Innovation Workgro

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

• June 23, 2006
• Premier Breakthrough Conference

Presented by Carla Provost, RN Baystate
Health Cathy Ivory, RN Johnson City Medical
Center, MSHA Sue Gullo, MS, RN IHI Kathy
Connolly, RN, MSEd, CPHRM Premier
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• Five recurring clinical issues are responsible
• for majority of perinatal harm and associated
• obstetrical professional liability
• Failure to recognize fetal distress/non-reassuri
  ng
• fetal status
• Failure to effect a timely cesarean birth
• Failure to properly resuscitate a depressed
  baby
• Inappropriate use of Oxytocin/Cytotec
• Inappropriate use of vacuum/forceps

Median Medical Malpractice Awards for Specific
Liability Situations, 1997-2003
JCAHO Root Causes of Perinatal Deaths and
Injuries (1995-2004)
Source Jury Verdict Research - Horsham, PA
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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.

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The Process for Innovation

• Phase I 16 Teams
• Premier
• Premiers Healthcare Informatics and Insurance
  Management Services
• Ascension Health
• Perinatal Safety Alpha Ministries
• Phase II 26 Teams (10 New Teams)

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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 institutions
  internal standards for defense (e.g., consistent
  documentation, no lapses in documentation, no
  lapses in communication)

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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.

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Our work

• Phase I
• Elective Induction Bundle
• Augmentation Bundle
• Application of reliability model
• Common language
• Communication and Teamwork Training

• Phase II
• Common Interpretive Construct
• Reliability
• Perinatal Trigger Tool
• Patient Preference
• Identification of risk

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What are our outcomes?
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Johnson City Medical Center Progress with
Premier/IHI Perinatal Innovation Workgroup Project

• Catherine H. Ivory, RNC, MSN
• Clinical Nurse Specialist
• June 23, 2006

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JCMC Augmentation Bundle
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Augmentation Composite
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Induction Bundle
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Induction Composite
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Perinatal Adverse Events
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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

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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.

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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.

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Progress with Premier/IHI Perinatal Innovation
Workgroup Project

• Carla Provost, RN
• Baystate Medical Center
• Springfield, MA
• June 23, 2006

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BAYSTATE TAKES LEAD!

• Baystate Medical Centers, 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. Whats
  their secret?

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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!

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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

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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

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Most promising changes

• The awareness of our units patient safety focus.
  Staff appreciate the teams challenge of the
  unspoken.
• Patient satisfaction is at an all time high.

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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.

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For more information about Premier/IHI Perinatal
Innovation Project, you may contact

• Premier, Inc.
• Kathy Connolly [phone] Email
  kathy_connolly_at_premierinc.com
• Kevin Davidson [phone]
• Email kevin_davidson_at_premierinc.com
• IHI (Institute for Healthcare Improvement) Sue
  Gullo [phone] Email sgullo_at_IHI.org

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Appendix Premier/IHI Perinatal Innovation
Workgroup

• June 23, 2006
• Premier Breakthrough Conference

Presented by Carla Provost, RN Baystate
Health Cathy Ivory, RN Johnson City Medical
Center, MSHA Sue Gullo, MS, RN IHI Kathy
Connolly, RN, MSEd, CPHRM Premier
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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

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Profile of Successful Teams

• Strong senior leadership and/or corporate
  support.
• Example- there will be no elective inductions lt39
  weeks at our facility
• Physician Champions

• Team members from the clinical frontline who are
  involved and empowered to identify and implement
  changes.
• Presented all information with the science behind
  it.

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Bundles

• Individual elements based on solid science
• Emphasis initially on process rather than outcome
• Based on failure modes
• Eventual endpoint is outcome improvement

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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.

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The Oxytocin Innovation Bundle

• Elective Induction Bundle
• Gestational Age gt/ 39 weeks
• Reassuring Fetal Status
• Pelvic Exam prior to the start of Oxytocin
• Recognition and management of Hyperstimulation

• Augmentation Bundle
• Documentation of Estimated Fetal Weight
• Reassuring Fetal Status
• Pelvic Exam prior to the start of Oxytocin
• Recognition and management of Hyperstimulation

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Tools Developed for Bundle Success-Example

• Hard stop in booking elective cases- no elective
  inductions (or elective cesareans) prior to 39
  weeks GA.
• Stopped at the booking point
• Prenatal record required on unit prior to booking
  of any procedure.
• Supported by the Physician Champion and backed up
  by the OB/GYN Department.

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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!

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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
( lt 2500 gm) ? Appropriate for Gestational Age
? Large for Gestational Age ( 4000 gms) Pelvic
Exam Dilatation _______ cm Effacement _______
Presentation Vertex ? Yes
Other______________ Station ____________ Membrane
s ? Intact ? Ruptured FHR Pattern ?
Reassuring ? Non-reassuring OTHER HISTORY/DATA
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Thomas Jefferson University Hospital
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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

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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.

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Situational Briefing Model

• S-B-A-R
• Situation
• Background
• Assessment
• Recommendation

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Johnson City Medical Center
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Johnson City Medical Center
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Johnson City Medical Center
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SBAR Examples

• Examples of other SBAR Tools on ihi.org from
  Seton Medical Center
• http//www.ihi.org/IHI/Topics/PerinatalCare/Perina
  talCareGeneral/EmergingContent/PerinatalSBARTools.
  htm

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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.

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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

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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

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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

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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!

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For more information on Fairview Southdales In
Situ Training,Please Contact-

• Kristi Miller, CNS
• kmiller5_at_Fairview.org
• Bill Riley, MD
• riley001_at_umn.edu
• Stan E Davis, MD
• SDAVIS5_at_Fairview.org

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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.
•  

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• T1 Apgar lt 7 at 5 min.
• T2 Admission to NICU and
• gt24 hours
• T3 Maternal/Neonatal
• Transport
• T4 Terbutaline
• T5 Naloxone
• T6 Infant Serum Glucose
• lt50
• T7 3rd or 4th Degree
• Lacerations
• T8 Prolonged decelerations
• T9 Blood Transfusion
• T10 Platelet count lt50000
• T11 Abrupt Medication Stop
• (e.g. epidural)

• T12 Hypotension/lethargy
• (Mom e.g. on Magnesium
• Sulfate)
• T13 Transfer to a Higher
• Level of Care, including ICU
• in-house
• T14 Unplanned return to surgery
• T15 Estimated blood loss gt 500 mL
• T16 Specialty Consult
• T17 Administration of oxytocic
• agents
• T18 Instrumented Delivery
• T19 Administration of general
• anesthetic for delivery
• T20 Cord gases ordered
• T21 Gestational Diabetes
• T22 Other

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What We Have Learned Thus Far From the Perinatal
Innovation Community
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Most Promising Changes

• Empowerment of the nurses in the management of
  uterotonic contractions.
• Continuing improvement within multidisciplinary
  communication.
• 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.

• Department pride in positive changes
• Orders and protocols evidence-based
• Documentation improved in completeness and
  accuracy
• Approval by OB/GYN department to limit elective
  inductions to 39 weeks or greater.

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Perinatal Teams- Assumptions Challenged

• Hyperstimulation- definition and impact to fetus
• That everyone described fetal monitor strips the
  same
• That everyone was utilizing appropriate
  communication
• I have worked with this nurse (or MD) for so
  long that we dont need to talk, we just know
  what to do.

• I know how to give report to a physician
• I am already Board Certified
• Protocols are not necessary for everyone
• Im too busy to participate
• The assumption that 38 ½ weeks was close enough
  to 39
• Providers and nurses need separate learning
  opportunities.

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Perinatal Teams- Assumptions Challenged

• Bad things dont happen to low risk patients
• Pitocin is not dangerous, we use it all the time.
• the baby will declare itselfpitting to
  distress
• If I just work harder or smarter I wont make a
  mistake

• Pit to distress
• But weve always done it this way!
• The use of less pitocin will delay active labor
  and increase length of time to delivery.
• Increase the pitocin past the non-reassuring
  FHTs or hyperstimulation
• Nurses dont question physicians

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Perinatal Teams- Surprises

• The difficulty experienced in engaging
  physicians in the efforts- discouraging due to an
  overall environment of very supportive medical
  staff.
• Positive outcomes
• Improved communications between all shareholders
• Everyone can improve their practice
• Champions may come from unexpected places

• We have had so few allegations and the
  defensibility of our documentation
• Fetal birth injury rate has dropped so
  dramatically
• Slow response to proposed changes
• Resistance to SBAR RN Recommendation
• Abiding to written policies and standards is very
  person dependent!

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Perinatal Teams- Surprises

• Concrete objective results!
• More pitocin is not always better!
• Hyperstimulation is not best practice!
• Compliance with changes
• Success breeds success
• Interdisciplinary teams can yield greater results
  
• Discovering that low risk patients are the most
  litigated with poor outcomes
• That the bedside nurses are being heard

• Our Model of Improvement with PDSA, small tests
  of change, and rapid cycle analysis actually
  works.
• Nurses and physicians were equally reluctant to
  use the new protocol
• Nurse/physician definitions of hyperstimulation
  and fetal status were varied and based on past
  experiences and training
• A patient really CAN deliver with less pitocon!