Getting Started on OB Adverse Events

1. Getting Started onOB Adverse Events Kelly Court Chief Quality Officer WHA

2. Today’s Call • Project Overview • Initiative Timeline and Process • Measures • Science Safety and Importance of Culture • Next 30 Days

3. Project Overview • Reducing Early Elective Deliveries • C-Sections • Elective Induction Bundle • Reducing Birth Trauma • Vacuum Assisted Deliveries • Use of NICHD Language in all Tracings • Team Training for Emergencies

4. Driver Diagram – Early Elective Deliveries Primary Drivers Secondary Drivers AIM

5. Driver Diagram – Birth Trauma Primary Drivers Secondary Drivers AIM

6. Poll Question #1 – What Drivers are Planning to Work On? Which areas of change are you planning to work on? (choose all that apply) • Early Elective Delivery – C-Sections • Early Elective Delivery – Inductions • Vacuum Assisted Deliveries • Fetal Tracings • Team Training • Still Unsure

8. Complications of Non-Medically Indicated (Elective) Deliveries Between 37 and 39 Weeks • Increased NICU admissions • Increased transient tachypnea of the newborn (TTN) • Increased respiratory distress syndrome (RDS) • Increased ventilator support • Increased suspected or proven sepsis • Increased newborn feeding problems and other transition issues

13. Poll Question #1 – Results Which areas of change are you planning to work on? (choose all that apply) • Early Elective Delivery – C-Sections • Early Elective Delivery – Inductions • Vacuum Assisted Deliveries • Fetal Tracings • Team Training • Still Unsure

14. Initiative Timeline Overview • 9 Month Collaborative • 1-Hr Webinar Each Month – 2nd Thursday of Each Month 12:00-1:00 PM

15. Initiative Learning Process Learning Opportunities Webinars • Review progress of last 30 days • New content • Discussion and sharing • Plan for the next 30 days Online discussion group • Questions • Peer-to-Peer Sharing Quality Center • Data submissions • Improvement tools and resources Site Visits Improve-ment Advisor

16. Theory of Constraints Reasons Improvement Projects May Have ‘Failed’ in the Past • Moved too fast to ‘Protocol and Procedure’ • Did not have the right people involved • Did not engage frontline staff in trying new changes – little buy in • Measures were not monitored consistently over time • Did not reinforce training on the new way of doing things • Used the same core group of people to fix the problem • Participants in the initiative do not address the root causes of performance deficiency

17. Overcoming the Constraints • Slow down the improvement train • Continuous measurement throughout initiative (and beyond) • Get the right people involved • Get new people involved • Small tests of change with many front-line staff • Opportunities to revisit training • Focus on project sustainability

18. Poll Question #2: How Would You Assess your Progress? Which of the following describes your facility best in terms of progress on this initiative? • This is the first time we have worked on it • We have worked on it in the past but feel we have regressed • We have really nailed it and are putting the finishing touches on the program • We have all but given up on finding ways to improve

19. Importance of Measurement Why measure? • The purpose of measurement in QI work is for learningnot judgment! • Measures should be used to guide improvement and test changes. • Demonstrate change from a baseline, or initial measurement, and assess the degree of change after an intervention. • Work on moving the process measures and the outcome measures should follow. I think we improved… but I’m not sure by how much?

20. Measures • Outcome Measures:Focus on the customer or patient. What is the result? • OB Outcome Measure: Admissions to NICU or Infant Transfer Following an Elective Delivery at <39 Weeks • Process Measures:Focus on theworkings of the system. Are the parts/steps in the system performing as planned? • OB Process Measure: Elective Deliveries at >=37 weeks and <=39 Weeks

21. Measures • Outcome Measures:Focus on the customer or patient. What is the result? • OB Outcome Measure: Birth Trauma – Injury to Neonate • Process Measures:Focus on theworkings of the system. Are the parts/steps in the system performing as planned? • OB Process Measures: • Vacuum assisted deliveries • Standard use of NICHD language on fetal heart tracings

22. Action Item #1 – Data Submission • Ensure baseline data for Outcomes measure has been submitted • Expectations for monthly submission • At least one process and one outcome measure • One month lag • Submit by the 30th of the following month

23. Poll Question #2: Results Which of the following describes your facility best in terms of progress on this initiative? • This is the first time we have worked on it • We have worked on it in the past but feel we have regressed • We have really nailed it and are putting the finishing touches on the program • We have all but given up on finding ways to improve

24. Science of Safety – How Errors Happen The Swiss Cheese Model – by James Reason Important Concepts: • Holes in any layer increase the vulnerability of the whole system. • It is virtually impossible to eliminate all holes. • Must understand the whole system, not just the steps. • Continuously monitor the health of the whole system.

25. Science of Safety Recipe • Educate on the Science of Safety • Identify Defects (Staff safety assessment) • Learn from Defects • Implement Teamwork & Communication Tools

26. Why Do Mistakes Happen? • Inconsistency/variation • Complexity • Too many/complicated steps • Human error • Tight time constraints • Hierarchical culture • Fatigue • Inattention/distraction • Unfamiliar situations/new problem • Communication errors • Using past solutions • Mislabeling/inadequate instructions • Equipment design flaws Process Factors People Factors

27. What is a “Safety Culture”? Safety Culture encompasses the attitudes held within a workplace, from the leadership to the front lines. Culture = “what you do when nobody is looking” This includes: • How open staff is to discussing patient safety issues and concerns with their colleagues and their leaders • How safe they feel about speaking out if they think that a patient is in danger • How serious they think the organizational leadership is about patient safety • How well they think they work as a team.

28. Patient Safety Video Think about sharing this video at a staff meeting: http://www.youtube.com/watch?v=GOJJHHm7lnM&feature=results_main&playnext=1&list=PL048D28C888FE3871

29. Organizing your Team Considerations • Who will you involve? • How will you communication? • Within your team? (notify of meetings) • To others outside of thee team? • How will you use the webinars? (use as weekly meeting?) • Identify team structure (key roles, expertise, leaders) • How will you keep everyone engaged?

30. Poll question #3: Where are you at? Which of the following best describes your progress on this initiative? • Team formed – AIM statement – Held first team meeting -- Analyzing interventions • Team formed – AIM Statement -- Held first team meeting • Team formed -- AIM Statement • Team formed • Just starting

31. Diverse and Independent Input Appreciate the wisdom of crowds • Remember health care is a team effort • Strive to create an environment where frontline providers can speak up if they have concerns and are heard when they express concerns • Get as many viewpoints as possible Alternate between convergent and divergent thinking • Divergent thinking – gathering lots of input and different ideas – useful when trying to understand what might be going on or possible solutions to solve a problem • Convergent thinking – occurs while formulating something specific - useful when finalizing an action plan or protocol

32. Action Item #3 - Organize your Team Agenda Team Charter Optional Tools to Use

33. Poll question #3: Results Which of the following best describes your progress on this initiative? • Team formed – AIM statement – Held first team meeting -- Analyzing interventions • Team formed – AIM Statement -- Held first team meeting • Team formed -- AIM Statement • Team formed • Just starting

34. Action Item #4 – Begin to Review the Resources for Change Review some of the key resources for change • HRET HEN Video – Eliminating Non-Medically Indicated Deliveries Before 39 Weeks - Dr. Joseph Derrough And/or • March of Dimes Toolkit

35. Guide to Quality Center http://www.whaqualitycenter.org/ Click Here

36. The Next 30 Days

37. Tools Available on WHA Quality Center • Meeting Agenda Template • Team Charter Template • Resources for Change • Video from HRET HEN Week • March of Dimes Toolkit

38. Questions?

39. Reminder Please complete the 3 question survey before you close out of the webinar window Thank you! Kelly Court Chief Quality Officer WHA