Perinatal Change Concepts: Prioritized By Highest Leverage within Each
Component of the Care Model

(Initial Output from Harvesting Meeting 2/11/06 and currently undergoing
refinement)

Current as of 3/7/2006

  --------------------------------------------------------------- ----------------------- ------------------------------------- ------------------------------------ ----------------------------- ------------------------------------------
  [**ORG**](#perinatal-and-patient-safety-ideas-tips-and-tools)   [**COM**](#community)   [**SMS**](#self-management-support)   [**DSD**](#delivery-system-design)   [**DS**](#decision-support)   [**CIS**](#clinical-information-systems)

  [Foster communication and coordination among FQHC, hospital,    [Form partnerships and  [Use effective self-management        [Create a uniform mechanism to       [Provide ongoing in-service   [Develop a registry system and process to
  and other agencies to ensure continuity, quality of care,       relationships with      support strategies that include       ensure timely record exchange        training for providers and    track clinically useful information and
  social supports and patient safety](#org1)                      community organizations assessment, goal-setting, action      between organizations.](#dsd1)       staff, using educational      data](#cis1)
                                                                  and specialists to      planning, problem-solving and                                              strategies proven to change   
                                                                  support and develop     follow-up](#sm1)                                                           practice behavior and         
                                                                  interventions that fill                                                                            integrating specialist        
                                                                  gaps in needed                                                                                     expertise, knowledge, and     
                                                                  services](#cis1)                                                                                   standards of care.](#ds1)     

                                                                                                                                [Give care that patients understand                                
                                                                                                                                and that fits with their cultural                                  
                                                                                                                                background](#dsd2)                                                 

  [Ensure that perinatal care and safety is a key part of the     [Increase awareness of  [Organize internal and community      [Develop a process and tool to allow [Embed evidence-based         [Organize and share information between
  strategic plan and a regular review of progress takes           and participation in    resources to provide ongoing          the patient to carry pertinent       guidelines into daily         the hospital and health center](#cis2)
  place](#org2)                                                   community programs and  self-management support to            medical history information.](#dsd3) clinical practice with the    
                                                                  build relationships to  patients](#sm2)                                                            development of protocols,     
                                                                  form alliances and                                                                                 standing orders, and flow     
                                                                  programming.](#com2)                                                                               sheets](#ds2)                 

  [Use an effective improvement strategy and supply appropriate   [Advocate for policies  [Develop opportunities for prenatal   [Utilize a tracking system.](#dsd4)  [Establish referral criteria, [Provide timely reminders and
  resources to optimize high quality care and patient safety      to improve patient      classes on site](#sm3)                                                     guidelines, and protocols     prompts](#cis3)
  outcomes](#org3)                                                care](#com3)                                                                                       that facilitate links with    
                                                                                                                                                                     supportive specialists,       
                                                                                                                                                                     community programs, and       
                                                                                                                                                                     support agencies](#ds3).      

                                                                                                                                [Provide clinical case management                                  
                                                                                                                                services for complex                                               
                                                                                                                                patients](#dsd5)                                                   

  [Assure the provision of culturally and linguistically                                  [Develop and utilize patient          [Develop and implement standardized                                [Facilitate individual patient care
  appropriate services for all by integrating the CLAS standards                          educational materials in a culturally antepartum visits utilizing                                        planning](#cis4)
  throughout the health system](#org4)                                                    competent manner](#sm4)               comprehensive forms and                                            
                                                                                                                                guidelines.](#dsd6)                                                

                                                                                                                                [Proactively plan and critique                                     
                                                                                                                                emergency drills](#dsd7)                                           
  --------------------------------------------------------------- ----------------------- ------------------------------------- ------------------------------------ ----------------------------- ------------------------------------------

# 

# [Perinatal and Patient Safety Ideas, Tips, and Tools]{.smallcaps} 

# [Found to be Helpful Within each of the Change Concepts]{.smallcaps}

**COMPONENT OF THE CARE MODEL**

1.  **Change Concept**

    a.  Change ideas

        i.  *Tips and tools*

# 

# 

# 

# ORGANIZATION OF HEALTHCARE

1)  []{#org1 .anchor}**Foster communication and coordination among FQHC,
    hospital, and other agencies to ensure continuity, quality of care,
    social supports and patient safety**

    a.  Monthly meetings with partnering teams across the continuum

    b.  Meet with state officials from Maternal and Child Care

    c.  Identify a champion in all associated organizations and identify
        their expertise (administration and clinician alike)

    d.  Development of a strong hospital and health center relationship

    e.  Establish a formal agreement with partners for an interim
        meeting (peer review protocol and practice sharing) to aid
        communication.

    f.  Develop mutual communication format (notes, e-mail, phone
        conference)

    g.  Cross training and sharing of experienced staff perception and
        skills to facilitate an understanding of each other and patient
        care at both the nursing and provider level.

    h.  Establish a strong working relationship among perinatal and
        neonatal practices

2)  []{#org2 .anchor}**Ensure that perinatal care and safety is a key
    part of the strategic plan and regular review of progress takes
    place**

    a.  Review strategic and performance improvement plans to ensure
        that the perinatal goals and measures are included therein.

    b.  Perinatal objectives and goals presented to the Board of
        Directors

    c.  Quarterly updates at health center staff meetings with CEO
        updates on measures and successes

    d.  Monthly reports to Board of Directors as a standing item on the
        Board report.

    e.  Monthly update in the staff newsletter.

    f.  Opportunity provided at medical staff meeting to give an update
        on progress and provide time for interaction and questions.

3)  []{#org3 .anchor}**Use an effective improvement strategy to optimize
    high quality care and patient safety outcomes**

    a.  Provide appropriate resources and support for a comprehensive
        quality program

    b.  Clinical information system access in all sites

    c.  Perform monthly performance improvement audits and follow-up.

    d.  Perform an audit of Emergency Room Records

4)  []{#org4 .anchor}**Assure the provision of culturally and
    linguistically appropriate services for all**

    a.  Identify demographics of the target population

    b.  Hire bilingual staff and interpreters

    c.  Information must be translated in the appropriate language and
        at the appropriate educational level

    d.  Staff training in cultural competency

    e.  Use peer groups to meet the needs of the target population

    f.  Incorporate cultural competency in the job description and
        performance appraisal of staff

        i.  *Cross Cultural Communication in Health Care -- Building
            Organizational Capacity -- Health Resources and Services
            Administration.
            <http://www.hrsa.gov/financeMC/broadcast/default.htm>.*

        ii. *Cultural Competency in Medicine -- American Medical Student
            Association -
            <http://www.amsa.org/programs/gpit/cultural.cfm>. .*

        iii. *Underserved Populations, Cultural Competency -- The
             Commonwealth Fund -
             <http://www.cmwf.org/topics/topics.htm?attrib_id=12024>.*

        iv. *AoA Programs -- Cultural Competency - Administration on
            Aging -
            <http://www.aoa.gov/prof/adddiv/cultural/addiv_cult.asp>.*

        v.  *Intercultural Competency Resources -- Diversity Training
            University international -
            <http://www.dtui.com/resource.html>.*

        vi. *Mitigating Health Disparities through Cultural Competence
            -- HRSA, HIV/AIDS Bureau.
            <http://hab.hrsa.gov/publications/august2002.htm>.*

        vii. *http://www.umdnj.edu/culturalcompetency/pages/whatis.htm
             What is Cultural Competency -- University of Medicine and
             Dentistry of New Jersey.
             <http://www.umdnj.edu/culturalcompetency/pages/whatis.htm>.*

        viii. *The Cross-Cultural Healthcare Program -
              <http://www.xculture.org/>.*

        ix. *Quality and Culture -- Bureau of Primary Health Care.
            <http://www.bphc.hrsa.gov/quality/Cultural.htm>*

### COMMUNITY

1.  **Form partnerships and relationships with community organizations
    and specialists to support and develop interventions that fill gaps
    in needed services**

    a.  Evaluate the gaps in the services you are providing
        (Availability of perinatal records identified by all
        organizations as a gap in services.)

        i.  *Footprint card (tool to be posted) given to expectant moms
            to bring to every visit.*

            -   *Keep all information confidential*

    b.  Identify agencies and people with whom you can have a
        conversation (new or established relationships)

    c.  Have a face to face meeting as soon as possible with interested
        agencies and organizations to determine opportunities for
        relationships and reciprocity.

        i.  Example: *Agreement to use business card and cell phone for
            the drug treatment coordinator on-call 24/7. (*PCC Wellness)

        ii. Example: *Domestic violence and abuse referral to community
            help agencies with the use of the "Mom's Card".*

            -   *Tip: Place card in restroom to be used during urine
                collection*.

        iii. *Offer something in return. For example, go to speak to
             their agency about a topic for which they have an
             interest.*

             -   *Tip: Keep looking for multiple and mutual benefits.*

    d.  Identify and agree on a referral process between interested
        agencies,

        i.  *Referral form* (Aaron E. Henry, Lela Keys)

        ii. *Have a system of follow-up care for missed appointments*

        iii. *Develop a standardized release of information form among
             agencies*

    e.  Set up a follow-up meeting

        i.  *Compile statistics to share between agencies*

        ii. *Nurture the relationships with open and frequent
            communication.*

    f.  Implement by testing the referral process on a couple of
        patients and continue to refine process with multiple testing.

2.  []{#com2 .anchor}**Increase awareness of community resources and
    build relationships to form alliances and programming.**

    a.  Identify community resources

        i.  *Healthy Start/Head Start*

        ii. *Perinatal educator within the community*

        iii. *State Department of Health for patient education
             materials*

        iv. *Faith based support groups*

        v.  *WIC*

    b.  Identify key people and establish contacts.

    c.  Pool resources with and of health centers and hospitals to
        prevent duplication and improve the quality of information.

    d.  Develop resource and contact lists and make them available for
        the health center, hospital, and community.

        i.  *Update contact lists regularly and distribute during the
            perinatal collaborative meetings.*

3.  []{#com3 .anchor}**Advocate for policies to improve patient care**

    a.  Identify the change agents that have the biggest impact on
        policy funding and support

        i.  *Example: Closing the Gap Risk Reduction Program*

        ii. *Keep all participants involved from the beginning to the
            end until the development and unity of objectives is
            achieved.*

    b.  Include as many mutual advocates with similar goals and
        objectives as possible

        i.  *Do not let any one advocate or organization dominate the
            discussion*

        ii. *Invite and encourage full participation.*

    c.  Advocate for policies to improve women's healthcare based on
        documented need and effective outcomes.

        i.  *Resources include the state Office of Vital Statistics
            regarding community mortality and morbidity rates and
            mortality early entrance in prenatal care.*

    d.  Clearly identify what the gaps are in perinatal and patient
        safety

        i.  *State legislators are a tool. Educate them, give them data,
            tell them stories with the expectation to take it to the
            state level and ask them to report back. "You work for
            me....you need to listen".*

        ii. *Look for media opportunities...anything that connects human
            (real people) to a policy concept.*

        iii. *Identify any leader/funder that is particularly friendly
             or effective and keep working with them.*

        iv. *Bend/stretch concepts and ideas according to what is
            available to maximize the resources. An example being: if
            smoking cessation or diabetes is a current focus or
            strategy, show the alignment of that focus with perinatal
            care.*

### SELF-MANAGEMENT SUPPORT

1.  []{#sm1 .anchor}**Use effective self-management support strategies
    that include assessment, goal-setting, action planning,
    problem-solving and follow-up**

    a.  Get significant family members involved in the care

        i.  *Let the patient determine who the significant other will
            be.*

    b.  Design a pamphlet on self management goal sheet.

        i.  *Bubble sheet self management goal sheet* (GA Carmichael)

    c.  Self management bubble sheet used at every visit/psychosocial
        assessment

    d.  Patient to set at least one self management goal for the month.

        i.  *Have patient use the footprint card to document their
            personal goal each month*.

    e.  Provide incentives for participation in self care (GA Carmichael
        has a ramp of PDSA cycles for this idea)

        i.  Car seats and other baby items given to participants if the
            program is completed. (GA Carmichael)

        ii. Treasure chest (Aaron E. Henry) item for each prenatal visit
            attended.

    f.  Ascertain the confidence level of the patient utilizing the 5A's
        approach.

        i.  <http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSupport/EmergingContent/5AsBehaviorChangeModel.htm>

        ii. <http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSupport/EmergingContent/#Tools>

        iii. <http://www.ahrq.gov/clinic/3rduspstf/behavior/behsum2.htm#FiveA>

        iv. *Crucial to make follow-up contact*

        v.  *Explanation mail and letter to patient on self management.*

2.  []{#sm2 .anchor}**Organize internal and community resources to
    provide ongoing self-management support to patients**

    a.  Review and refine self management tool as needed

        i.  *Self management goal sheet (DCHC, Julie Giroux)*

            -   *Necessary to follow-up with the self management goal at
                least every trimester.*

        ii. *Goal sheet developed for fathers relating to domestic
            violence (DCHC, Julie Giroux)*

            -   *Placed in patient bathrooms (both male and female)*

    b.  Link faith based organization screening programs to a specific
        person at the health center

    c.  Partner with other collaborative work to disseminate patient
        education about perinatal care issues at schools, churches, etc.

    d.  Primary care advocate to link patients, such as a walk in or
        no-doc patients linked to the clinic

        i.  *Make sure that you have the correct contact information or
            outreach efforts will be impeded*

        ii. *The Outreach Form (PCC Wellness, Melvina Jenkins)*

    e.  Hospital tours for OB patients and their families

        i.  *A pitfall if there are no individual tours available for
            those who do not attend a prenatal class.*

        ii. *Tour agenda and schedule (Beaufort Memorial; DCHC/Hutzel
            Hospital, Sylvia Cox)*

3.  []{#sm3 .anchor}**Develop opportunities for prenatal classes on
    site**

    a.  Collaborative with hospital to get patients into classes on
        hospital campus (PDSA ramp available through Detroit)

    b.  Initiate classes on site at the health center to accommodate
        other patients, with the hospital setting a nurse to teach.
        (PDSA ramp available through Beaufort Jasper)

        i.  *Place fliers throughout the community (beauty shops, barber
            shops, laundromats)*

        ii. *Provide incentives for the mom to encourage to participate
            (car seats, gift bags) Detroit Community Health Center,
            Linda Atkins.*

        iii. *One day session from 9 am-4 pm providing child care and
             transportation worked well at Detroit Community.*

        iv. *Curriculum for eight hour class (Contact: Sylvia Cox,
            Harper Hospital; Patti Woodward, Beaufort Memorial
            Hospital)*

        v.  *Incentives script with printed information about prenatal
            class signed by the physician and given to the patient (PCC
            Wellness, Andrea McGlynn*

            -   *The script was more effective than a flier*

            -   *Fliers were placed in all rooms and bathrooms*

4.  []{#sm4 .anchor}**Develop and utilize patient educational materials
    in a culturally competent manner**

    a.  Nurse initiates the patient educational assessment form that is
        used on all patients

        i.  *Educational level*

        ii. *How they like to receive information*

        iii. *Provider and patient pick educational topic*

        iv. *Includes assessment of patient understanding; if poor,
            repeat and re-demonstrate*

        v.  *Provide an accent on health video information accessed in
            patient waiting room*

            -   *Use cycles for different topics*

            -   *Change frequently to cover different topics*

    b.  Research organizations that already have literature that is
        culturally sensitive

        i.  *Domestic violence screening cards*

        ii. *Domestic violence flyer available to all patients*

        iii. *Translate common terminology used in practice to be able
             to communicate if no translator is available.*

        iv. *CDC, AAP, Public Health Department, NICHQ website.*

### DELIVERY SYSTEM DESIGN

1.  []{#dsd1 .anchor}**Create a uniform mechanism to ensure timely
    record exchange between organizations**.

    a.  Identify high risk OB's and gestational age for delivery of
        records to the health center at 28 weeks**.**

        i.  *High risk OB team that includes: Provider, social worker,
            clerk, nurse.*

        ii. *The clerk delivers records daily.*

        iii. *Identify a person at each site that is responsible for
             filing of the records*

    b.  All OB records at the hospital by 32-34 weeks

    c.  Unattached patients with hospital visit need records sent to
        provider site for scheduled appointment

        i.  *Triage "package" folder*

    d.  Post partum/newborn stamped envelope for clinic with records
        included for the patient to carry to the first follow-up visit

        i.  *Duplicate or triplicate records*

        ii. *List of OB patients to Labor and Delivery for returned
            records if patient presents to ED*

2.  []{#dsd2 .anchor}**Give care that patients understand and that fits
    with their cultural background**

3.  []{#dsd3 .anchor}**Develop a process and tool to allow the patient
    to carry pertinent medical history information.**

    a.  Develop "footprint" card or some form with critical information
        such as demographics, labs, medication, patient language, labor
        management, significant other at delivery, initial visit, family
        history, surgical history, breast or bottle, date for each
        visit, vitals, FHT.

    b.  Give card at first prenatal visit.

        i.  *Have cards in different languages.*

        ii. *Ask for the footprint card at every visit.*

4.  []{#dsd4 .anchor}**Utilize a tracking system.**

    a.  OB list sent to women's center monthly

        i.  *Computer and hospital log book*

        ii. *Need hospital support*

    b.  OB log set up on hard drive to include a list of all pregnant
        patients that enter into care.

        i.  *Computer and hospital log book*

        ii. *Support from medical records to print delivery patient.*

        iii. *Lack of tracking system of patient delivery elsewhere can
             be problematic.*

    c.  UDS prenatal log on all pregnant patients.

5.  []{#dsd5 .anchor}**Provide clinical case management services for
    complex patients**

6.  []{#dsd6 .anchor}**Develop and implement standardized antepartum
    visits utilizing comprehensive forms and guidelines**.

    a.  Identify barriers and gaps for comprehensive antepartum care to
        be done time appropriately

        i.  *Health problems not being identified early*

            -   *Perinatal flow sheet*

            -   *Gestational age calculator computer base done initially
                by the front desk*

            -   *Have comprehensive health care screening done at the
                first or second visit by the provider, which provides an
                earlier risk assessment.*

        ii. *Psychosocial issues not being identified*

            -   *Comprehensive psychosocial and depression screening
                form*

        iii. *Unattached patient presenting to triage*

             -   *Assessment form for unattached patient (*PCC
                 Wellness, A. McGlynn*)*

             -   *Form should be faxed to the clinic site to which the
                 patient is assigned.*

    b.  Post partum depression screening by two weeks

        i.  *Have mother and baby come for appointments together*

        ii. *Modified PHQ (PCC Wellness, Andrea McGlynn)*

        iii. *Attach PHQ to early post partum assessment sheet and
             ensure it gets done.*

    c.  Specific prenatal care days for each provider

        i.  *Able to batch service to provide a comprehensive OB visit:
            social work, financial counselor, health educator all
            present on the same day.*

7.  []{#dsd7 .anchor}**Proactively plan and critique emergency drills**

    a.  Presentation to key players regarding what is needed to drill,
        using literature and evidence based practice

        i.  [www.awhonn.org](http://www.awhonn.org/)

        ii. [www.acog.org](http://www.acog.org/)

    b.  Develop drill for shoulder dystocia, post partum hemorrhage,
        emergency c-section

        i.  *Make sure that the drills are video taped*

        ii. *Pro-actively schedule the drills*

    c.  Documentation component (collaborative tool)

    d.  Decide where the tool will be kept

    e.  Education for all players: providers and staff

    f.  Decide on frequency of drills

        i.  *All shifts, including weekends*

        ii. *Quarterly, at a minimum*

    g.  Develop method of critiquing the drills in a collaborative
        setting

    h.  Clearly define the roles and responsibilities of players:
        recording, leading, etc.

    i.  After critiquing, ensure that there is follow-up to improve the
        process

    j.  Disseminate the results of the critique to the community

### DECISION SUPPORT

1.  []{#ds1 .anchor}**Provide ongoing training to stay up-to-date on the
    latest guidelines and evidence**.

    a.  Establish components that are important to review in chart
        audits

        i.  *Chart audit check list: labs ordered and signed off,
            antepartum note to hospital, and referrals followed up.*

        ii. *Train staff on the use of the form*

        iii. *Train staff on ACOG/AOA/AWHONN/AAFP guidelines*

    b.  Regular scheduled meeting between management and OB/GYN staff

    c.  Case conference between health center and hospital labor and
        delivery department

        i.  *Build into existing meetings*

        ii. *Make CME time out of meeting*

2.  []{#ds2 .anchor}**Embed evidence-based guidelines into daily
    clinical practice with the development of protocols, standing
    orders, and flow sheets**

    a.  Develop an OB flow sheet (Aaron E. Henry)

    b.  Create standing orders. For example, Glucola (PCC Wellness)

    c.  Development of protocols for high risk patients

        i.  *Assign a level of risk*

        ii. *Develop care plan*

        iii. *Consultation obtained*

        iv. *Documentation*

    d.  Identify potential prevention of high risk shoulder dystocia
        (code shoulder)

        i.  *ACOG guidelines available*

        ii. *Adherence to protocols should be monitored*

        iii. *Mock drills are important*

3.  []{#ds3 .anchor}**Develop guidelines and protocols for the
    involvement of supportive specialists in the care of more complex
    patients**

### CLINICAL INFORMATION SYSTEMS

1.  []{#cis1 .anchor}**Develop a registry system and process to track
    clinically useful information and data**

    a.  Develop an approach/strategy for staring to use the registry
        system. Options include:

        i.  *entering established patients first: make sure that you
            enter demographics and a summary of previous visits (PCC
            Wellness Chart Abstraction Form, <mkita@pccwellness.org> )*

        ii. *Entering new patients as they begin care: slower process
            and does not give the full picture of your population as
            quickly*.

    b.  Consider hiring additional staff or cross training current staff
        to do data entry.

        i.  *Recruit and train additional PECS workers on the perinatal
            variables so that the maximum number of patients can be
            entered quickly*

        ii. *One staff member can abstract charts and others can enter
            the data*

        iii. *If available, use a computer program to merge patient
             demographics from the billing system to the registry*

    c.  Routinely enter data from visits into the registry to update
        existing patients in the system

        i.  *Chart comes to data entry person after the visit*

        ii. *Sticker on the chart to indicate pregnant patient (SAFETY)*

        iii. *Keep a list of the patients with visits to make sure that
             all get updated.*

    d.  Develop a mechanism to know of new patients

        i.  *Use of an existing case management list*

        ii. *Use of lists generated from billing data with a diagnosis
            code for pregnancy (PCC Wellness, List of Pregnancy
            Diagnosis Codes, <amcglynn@pccwellness.org> )*

    e.  Generate data for quality improvement for the system, by
        provider, and for reporting

    f.  Generate data to prompt needed care and referrals, such as the
        creation of a query to identify all patients using tobacco
        products and send them to a smoking cessation specialist.

2.  []{#cis2 .anchor}**Organize and share information between the
    hospital and health center**

    a.  Scan prenatal record and delivery noted into information system
        that is shared by hospital and clinic

    b.  Create forms in duplicate for delivery note and send a copy to
        the clinic

    c.  Follow-up the transfer of care such as NSTs and no-shows.

    d.  Start at first with sending the patient information to the
        hospital to register and "create a patient" at the hospital.

    e.  Use a bidirectional computer interface for labs (if done at the
        hospital get results at the clinic and vice versa.

    f.  Share the clinic's case management list of high risk patients
        for the hospital joint practice discussion.

    g.  Train all people at the clinic to use the hospital CIS after
        getting access to hospital CIS at the clinic level.

    h.  Scan prenatal record into the CIS and troubleshoot problems on a
        small level

    i.  Daily courier trip to hospital, FAX, or take to L&D receptionist
        for filing.

3.  []{#cis3 .anchor}**Provide timely reminders and prompts**

    a.  Identify/establish a key data entry person(s)

    b.  Use prompts and reminders in the clinical information system

    c.  Educate and train on the key measures, medical terminology, and
        chart extractions for key data entry person(s)

    d.  Registry training sessions to provide cross training for all
        staff

4.  []{#cis4 .anchor}**Facilitate individual patient care planning**

    a.  Create a perinatal flow sheet, with reminders when possible

    b.  Develop a tool for reviewing charts and encounter forms

    c.  Review charts before the patient visit at least 24 hours prior
        to the appointment

    d.  Identify specific patient needs at the time of the scheduled
        visit by using the results of the chart audit/review

    e.  Update records at the time of or after the visit.