Listening to our PatientsB-3 10:45-12:00pm

Sue Gullo, RN, BSN, MSManaging Director

Institute for Healthcare Improvement (IHI)

OBJECTIVES

• Describe national surveys that provide information on what women want.

• Discuss the components of patient centered care.• Identify 3 interventions that can be accomplished

on your unit to support patient centered care.• Assess your unit’s culture and use quality

improvement methodology to create a culture based on the patients’ needs.

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Perinatal Oxytocin Bundles

Perinatal Trigger Tool

Common EFMLanguage and

Training

ReduceVariation-

Meds, Emergencies

Implement Techniquesfor Effective

Communication

Engage Patients and

Families

Establish a multi-

disciplinary team training program

Establish Huddles,

Multi-disciplinaryrounds

DesignInterventionsFrom TriggerTool findings

Consistent (across disciplines)

CredentialingStandards

CollaborativeAnd Supportive

Culture

Vacuum Bundle

•Effective Team with Active Sponsor•Senior Admin and Board Level Support

3 m

on

ths

to 3

6 m

on

ths

Oxytocin Deep Dive- Pre-work

1-3 months 3-6 months

6-9 months

9-12 months

12-24 months

Patients on Improvement

Teams

Care is transparent

Second Stage Safety

Perinatal Community

• Leadership help establish aims & goals• Senior Executives support sponsor• Assist in identification of needed resources and develops plan

to provide• Competent trained available staff

Leadership and Sponsor

• Implement oxytocin and vacuum bundle• Develop standard protocols for response to obstetrical

emergency • Design care process improvements based on trigger tool

analysis, event detection, sentinel event• Establish credentialing of core competency and training for all• Use ACOG/AWHONN guidelines for documentation and

staffing• Standardize administration of high alert medications –

oxytocin, magnesium sulfate, epidurals

Reliable DesignReduce Variation

• Adopt common language and interpretation of EFM with multi-disciplinary training i.e NICHD criteria

• Implement techniques for effective communication i.e. SBAR• Establish reliable techniques for handoffs• Establish Team Response Protocols• Establish a just culture – create consistent expectations for

performance and behavior across all disciplines • Implement Huddles• Design Simulations

Effective Teamwork

• Add patients and families on design teams, advisory groups• Co-create and discuss a plan of care with the patient and

family Conduct Patient/Family Focus Groups• Engage patients & families as partners in care• Communicate openly and honestly with family and patients at

regular intervals • Do what you say, mean what you do • Include patients and families on improvement teams

Patient/Family Centered Care

Reduce harm to 5 or less per 100 live

births

Zero incidence of elective deliveries prior to 39 weeks

Augmentation Bundle(s) Composite or Compliance great

than 90%

Improve organizational

culture of safety survey scores in

Perinatal units by 25%

100% of participating teams will have

documentation of Patient & Family

Centered Care

Nothing about me, without me.

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Core Concepts of PCC

http://www.ipfcc.org/

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Respect and dignity

• Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

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Information Sharing

• Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making

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Participation

• Patients and families are encouraged and supported in participating in care and decision-making at the level they choose.

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Collaboration

• Patients and families are also included on an institution-wide basis. Health care leaders collaborate with patients and families in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care.

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2 Key Documents

• “Evidence Based Maternity Care: What It Is and What It Can Achieve”

http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf

• Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives

http://www.marchofdimes.com/TIOPIII_FinalManuscript.pdf

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Stakeholders

• Policymakers

• Healthcare professionals

• Childbearing women

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“The First Law of Improvement”

“Every system is perfectly designed to achieve exactly

the results it gets.”Paul Batalden

2002

• The landmark Listening to Mothers I survey (2002) was the first time that women in the United States were surveyed at the national level about their maternity experiences.

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2006 Cost of Interventions- Misuse, Overuse, Underuse Underuse

“Only a small proportion of women experienced these beneficial practices:

use of highly rated drug-free methods of pain relief (e.g., immersion in a tub, shower, use of large "birth ball"), monitoring the baby with handheld devices instead of electronic fetal monitoring, drinking fluids or eating during labor, moving about during labor, giving birth in non-supine positions, and pushing guided only by their own reflexes rather than caregiver-directed pushing.”

http://www.childbirthconnection.com/pdf.asp?PDFDownload=LTMII_pressrelease15

Childbirth is the #1 reason for hospital admission

Cesarean birth is the #1 surgical procedure in the United States.

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Change in Distribution of Births by Gestational Age: United States, 1990-2006

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2009.

Source: CDC/NCHS, National Vital Statistics Systems.

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U.S. Cesarean Section and Labor Induction Rates Among Singleton Live Births by Week of Gestation, 1992 and 2002.

Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.

2002 Induction

2002 C-S

1992 C-S

1992 Induction

Ear

ly T

erm

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Rates of Induction of Labor by Race and Hispanic Origin in the U.S.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7.Hyattsville, MD: National Center for Health Statistics. 2009.

20http://www.cdc.gov/nchs/data/databriefs/db24_fig5.png

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www.ihi.org

Key Theme

• An integrated system is key to achieving the aim of an excellent patient and family experience of inpatient hospital care.

• For example, excellent partnerships with patients contribute to safer care, and safer care results in better patient experiences.

Key Theme

• Leadership behavior at the executive, middle, and front-line levels is essential to achieving exceptional results.

• Leadership commitment to creating an environment that nurtures and continuously improves the patient and family experience and results in positive outcomes is essential.

Key Theme

• The path to achieving excellence in the patient and family experience includes a group of dynamic, positively reinforcing actions rather than a linear set of activities.

• For instance, effective leadership engages the hearts and minds of staff and providers, which in turn provides a foundation for respectful team communication and partnerships with patients and families, which in turn reinforces staff and provider engagement.

Safety Culture

Refers to the extent to which individuals and groups will:

• Commit to personal responsibility for safety • Act to preserve, enhance and communicate

safety concerns• Strive to actively learn, adapt and modify (both

individual and organizational) behavior based on lessons learned from mistakes or near misses

• Be rewarded in a manner consistent with these values

Listening

• Involves effective communication

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We are competent.

We have teamwork and communication failures.

• 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

Teamwork

“Perceptions of Teamwork in L&D” Journal of Perinatalogy, June 2006

• Only 55% of respondents found it easy to speak up if they perceived a problem with patient care, and only half felt that conflicts were appropriately resolved.

• “In medicine, questions seeking advise or knowledge are welcome, whereas questioning someone’s performance or disagreeing with their actions is taboo.”

• Communication breakdowns• Resentment or indifference to team concept • Competing priorities and goals among team

members• Language problems• Failure to compromise with goals• Poor coordination of activities among team

members• Role confusion – Role conflict

Negative Team Factors

What Impacts Our Performance?

• Fatigue• Lack of sleep• Illness• Drugs or alcohol• Boredom• Frustration• Fear • Stress• Shift work• Reliance on

memory• Reliance on

vigilance

• Distractions• Noise• Heat• Clutter• Motion• Lighting• Too many handoffs• Unnatural workflow• Procedures or devices

designed in an accident prone fashion

Provider Perspective

“In medicine, it is a challenge to be the one to criticize or evaluate a colleague when you perceive that mistakes are being made, or when you disagree with management.”

Sharp End

Case Study: “A 38-Year-Old-Woman With Fetal Loss and

Hysterectomy”

JAMA, August 17, 2005- Vol 294, No 7

Benjamin P. Sachs, MB, BS, Discussant

Background

“38 year old woman admitted to the hospital for elective delivery of her first child, but the admission ended tragically with fetal loss, hysterectomy, and a prolonged hospitalization.”

Dr. Sachs

“Although the complication that occurred is rare, unfortunately the types of failures in communication and teamwork are not.”

6 System Failures Identified

1. Communication was poor

2. Mutual performance cross monitoring

3. Inadequate conflict resolution

4. Poor situational awareness

5. Physician workload was too high and there was no contingency plan in place to deal with the overload

6. Physician on call displayed “vigilance fatigue”

Lessons Learned

Patients and Family:

• Appropriate consent

• Communication

• Feeling safe

• Able to ask for additional help “Code H”

“A Reason to Change”

Luke Vincent Powers September 11, 2009

Presented by:

William Powers

Discussion

1. What do you do well, and why?

2. What can you do better, and why?

3. What would you do differently, and why?

What would you like to improve?

• Why?

• How do you know? What are your current results?

• How will you know a change is an improvement?

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What can every one of you do tomorrow?

1. No longer accept the status quo- ask why?

2. Start with one patient, one nurse, one doctor.

3. Stop the line when it is not right.

4. Love what you do.

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study DoSource:

Langley, et al. The Improvement Guide, 1996.

The three questions provide the strategystrategy

The PDSA cycle provides the tactical tactical approach to work

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