# Presentation: 662996

## Idealized Design of Perinatal Care: Reliable Quality Care in Obstetrics

- Peter Cherouny
- Sue Gullo

## Quality Care in Obstetrics

*What we say*
- Priorities for Action were chosen based upon national indicators or data sets chosen by AHRQ, NQF, and/or other national safety organizations. Excellence in these priority areas...
- The strategy calls for an individual ministry to develop that blueprint, pilot the spread to four or five Beta sites, and then lead the dissemination of the strategy/change package...

## Quality Care in Obstetrics

*What we hear*
- Blah blah blah blah quality blah blah blah blah outcomes blah blah blah blah  blah blah  blah blah blah blah blah blah liability premiums going up blah blah blah blah blah blah blah blah blah blah blah blah outcomes blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah don’t mess up

## Objectives

- Overview of the Project
- Introduce and define the concept of Idealized Design
- Use the perinatal bundles as examples in this design process
- Results

## Why focus on perinatal care?

- Good science exists
- Significant variability in process.
- Care is provider driven rather than standardized.
- This autonomous practice focus contributes to the unreliable delivery of care.

## What’s in it for me?What would make our lives better?

- Prevent the preventable
- Defend the unpreventable

## Quality Care in ObstetricsWhy is this important now

## Quality Care in ObstetricsWhy is this important now

## Quality Care in ObstetricsWhy is this important now

## Quality Care in ObstetricsWhy is this important now

**NON-PREVENTABLE**

**PR****EVENTABLE**

## Quality Care in ObstetricsWhy is this important now

- _2004_
- 	_Birth trauma rate:_ 6.3-7.3/1000
- 	4,115,590 births in US

## Quality Care in ObstetricsWhy is this important now

- _26,000-30,000 injured babies_
- Cost, outcome, litigation implications

## Quality Care in ObstetricsWhy is this important now

- Despite being second in litigious events, the rate of claims is low; but payment is high.
**$23.8M award in childbirth lawsuit**
- By Scott Allen, Globe Staff*Boston Globe May 11, 2005***2 doctors faulted at Mass. General**
- In one of the largest malpractice verdicts in state history, a Suffolk County jury has awarded $23.8 million to the family of a girl born with cerebral palsy after a _***traumatic delivery***_ at Massachusetts General Hospital. Jurors took less than four hours Monday to find two Mass. General obstetricians negligent in the delivery in 1996

## Objectives

- Overview of the Project
- Introduce and define the concept of Idealized Design
- Use the perinatal bundles as examples in this design process
- Results

## What is Idealized Design of Perinatal Care?

- Based on the principles of reliability science
- Designing Our System of Care for Reliability

## What is Reliability?

- “Reliability is failure free operation over time.”**            **
**	****	****	****	****	****	****David Garvin ****                                        Harvard Business ****	****	****	****	****	****School**

## What is Idealized Design of Perinatal Care?

- The development of reliable clinical processes to manage labor and delivery (Pitocin Bundles)
- The use of principles that improve safety
- 	(i.e., preventing, detecting, and mitigating errors)
- The establishment of prepared obstetric care teams that communicate effectively with each other and with mothers and families

## Why Standardize?

- Contributes to building an infrastructure (who does what, when, where, how and with what)
- Support training and competency testing to sustain the process
- Achieve front line articulation of key processes by staff
- Allows the appropriate application of Evidence Based Medicine consistently
- Feedback about errors and application of learning to design is possible

## Quality Care in ObstetricsAre we standardized?

## Quality Care in ObstetricsAre we standardized?

## Quality Care in ObstetricsAre we standardized?

- How many different Pitocin protocols are there on L&D?

- This week?

- Right now?

## Quality Care in ObstetricsWhat about human factors?

## Individual Autonomy

**PERFORMANCE**

**Guidelines as defined by professional standards**** *****Legal space***

**Usual space**
**of action**
***Illegal-normal***
***space***

**the ‘illegal-illegal’ space (for almost all of us!)**

**VERY UNSAFE SPACE**

- Individual
- Pressures

- Perceived
- Vulnerability

- Belief in
- Systems-
- guidelines

**<1%              5%                   50%    80%    100%  percent of staff**

**Safety regs**
** ****& good practices**
**Certification/ **
**accreditation **
**standards**

**Collective**
** ****memory of **
**experiences**

**Forbidden**
**behavior except **
**under extreme **
**circumstances**

**Forbidden**
**by all**

## What are we Standardizing?

- Communication standardization
- SBAR
- Practice Standardization
- Clinical Bundle

## Communication standardizationWhat we say

- Why communication is the heart of the matter
- Everyone in the Same Movie – No Surprises
- Tools and behaviors to insure effective communication and teamwork

## Highly Reliable Perinatal Unit

- SBAR to communicate
- MD always comes when RN/ midwife requests
- Definition of fetal well being
- Common definition of  fetal heart tracing
- Practicing for emergencies

## Why Focus on Communication?

- The overwhelming majority of untoward events involve communication failure
- Somebody knows there’s a problem but can’t get everyone in the same movie
- The clinical environment has evolved beyond the limitations of individual human performance

## Slide 29

## Slide 30

## JCAHO Sentinel Events

- Communication breakdowns remain the primary root cause of more than 70% of the 2400 sentinel events analyzed
- Virtually all had communication failures
- The majority of sentinel events (75%) resulted in a patient death

## Elements of  Effective Communication

- Structured communication – SBAR
- Assertion/ Critical Language – key words, the ability to speak up and stop the show
- Psychological safety – an environment of respect

## Situational Briefing Model

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

## SBAR

**Situation** – the punch line 5-10 seconds
**Background** – the context, objective data, how did we get here
**Assessment** – what is the problem?
**Recommendation** – what do we need to do ?

## Sustaining SBAR Use

- “Give it to me in SBAR”
- Use prompts and ticklers
- Checklists
- Phone labels
- Pocket cards
- “Thanks for using SBAR”
- Reward and recognize

**Notes:**
If the person on the receiving end of a communication notices the sender wondering off into a long narrative, ask for the briefing in SBAR format.  Or start your inquiry with “I need an update on Mr. Jones, can you give me an SBAR on his status/”
Reminders and checklists help remind staff on the elements of an SBAR communication and helps them be better prepared and organized  It’s awkward at first, prompts help make SBAR become part of the culture
Nothing works better than feedback that occurs immediately after the desired behavior, is certain to occur and is positive in nature.  Just saying thanks goes a long way in sustaining SBAR use
Formal reward an recognition to reinforce use and to collect stories and outcomes associated with the practice.

## Slide 36

## Practice standardizationWhat we do

- Standardization of process
- The Clinical Bundle

## What is a Clinical Bundle

- A group of clinical events that should happen every time a given process occurs
- Individual elements based on solid science
- Emphasis initially on process rather than outcome
- Based on failure modes
- Eventual endpoint is outcome improvement

## Into Thin Airby Jon Krakauer 

- A Lesson from the Outside

- _What is a Clinical Bundle_

## Assault on Everest Summit

- April and May, 1996
- Several commercial and independent teams
- Three “rivals”
- Very experienced, but failed to summit the prior season
- Less experienced, establishing business
- Little experience, well funded

## Assault on Everest SummitManaged Dangers

- Life-threatening altitude
- Life-threatening weather
- Life-threatening terrain

## Assault on Everest SummitReminders of Danger

- The thirty feet to the mess tent led to wheezing and shortness of breath
- Sitting up too fast led to vertigo
- Persistent headache
- Constant intestinal turmoil
- Rarely hungry; had to force feed

## Assault on Everest SummitHard and Fast Rules

- Acclimatization at altitude
- Work together
- Cannot assist someone on the ascent
- Fixed turn around time

## Assault on Everest SummitSummit Bundle

- Standard acclimatization techniques
- # days and at what altitude
- Work together
- Cannot assist someone on the ascent
- Fixed turn around time

## Assault on Everest SummitSummit Bundle

- Standard acclimatization techniques
- # days and at what altitude
- Practice team work (between and among teams)
- Cannot assist someone on the ascent
- Fixed turn around time

## Assault on Everest SummitSummit Bundle

- Standard acclimatization techniques
- # days and at what altitude
- Practice team work (between and among teams)
- No “short-roping” on the ascent
- Fixed turn around time

## Assault on Everest SummitSummit Bundle

- Standard acclimatization techniques
- # days and at what altitude
- Practice team work (between and among teams)
- No “short-roping” on the ascent
- No assisting with climbing on the ascent
- Turn around time fixed and honored
- (1 PM for most groups)

## Assault on Everest SummitComplicating Factors

- Experienced leader did not summit the prior season
- Charges $65,000/person
- Invited back a climber who was 200’ from the summit in 1995
- Less Experienced leader
- Had not previously guided on Everest
- Writer who was posting daily to the NBC WWW site
- One climber was completing the “Seven Summits” with this climb
- Inexperienced Leader lied about experience

## Assault on Everest SummitSummit Bundle Compliance

- All teams acclimatized but there was no standard (oxygen bottles scattered at differing altitudes)
- Teams refused to cooperate on timing through Hilary’s Step (one person rope)
- Some climbers were assisted on the ascent as it was felt they *had* to summit on this climb
- Turn around time was set but not honored
- Last summit was about 5 PM

## Assault on Everest SummitResult

- Experienced leader; summits at 3PM
- Less experienced leader; assisted two climbers up
- Inexperienced leader; 2 weeks later, split group up with one climber summiting at 5 PM

## Assault on Everest SummitSummit Bundle

- Standard acclimatization techniques
- # days and at what altitude
- Practice team work (between and among teams)
- No “short-roping” on the ascent
- No assisting with climbing on the ascent
- Turn around time fixed and honored
- (1 PM for most groups)

## Assault on Everest SummitResult

- Eleven Deaths

## The Clinical Bundle

- A group of clinical events that should happen every time a given process occurs

## Perinatal CommunityBirth Trauma

- Can we reduce birth trauma?
- Estimated that about 50% is potentially avoidable

##  What do we do to babies?
Soft tissue injuries
Nerve injuries
Bone injuries
Neurologic injuries

- Soft tissue injuries
- Nerve injuries
- Bone injuries
- Neurologic injuries

- Perinatal Community*Birth Trauma*

## Quality Care in Obstetrics Birth Trauma

*Causation*
- Large fetuses
- Operative vaginal deliveries (esp midpelvic & combined)
- Vaginal breech delivery
- Inappropriate use of pitocin
- Abnormal/excessive traction
- Inadequate assessment of fetal status

## Quality Care in ObstetricsBirth Trauma

*Prevention*
- Don’t deliver large fetuses
- Don’t do Operative vaginal deliveries
- Don’t do Vaginal breech delivery
- Don’t use pitocin
- Don’t pull too hard
- Interpret fetal status perfectly

## Quality Care in ObstetricsBirth Trauma

*Prevention*
- Practice Gynecology

## Quality Care in ObstetricsBirth Trauma and Pitocin

*Causation*
- Large fetuses
- Operative vaginal deliveries (esp midpelvic & combined)
- Vaginal breech delivery
- Inappropriate use of pitocin (hyperstimulation)
- Abnormal/excessive traction
- Inadequate assessment of fetal status

## Quality Care in ObstetricsBirth Trauma and Pitocin

*Causation*
- Large fetuses
- Operative vaginal deliveries (esp midpelvic & combined)
- Vaginal breech delivery
- Inappropriate use of pitocin (hyperstimulation)
- Abnormal/excessive traction
- Inadequate assessment of fetal status

## Quality Care in ObstetricsBirth Trauma and Pitocin

*Causation*
- Large fetuses
- Operative vaginal deliveries (esp midpelvic & combined)
- Vaginal breech delivery
- Inappropriate use of pitocin (hyperstimulation)
- Abnormal/excessive traction
- Inadequate assessment of fetal status

## Quality Care in ObstetricsBirth Trauma and Pitocin

*Causation*
- Large fetuses
- Operative vaginal deliveries (esp midpelvic & combined)
- Vaginal breech delivery
- Inappropriate use of pitocin (hyperstimulation)
- Abnormal/excessive traction
- Inadequate assessment of fetal status

## Quality Care in ObstetricsBirth Trauma, Pitocin, OVD

- Pitocin is involved in over 50% of the situations leading to birth trauma
- Operative Vaginal deliveries have serious complications 5% of the time

## The Oxytocin Innovation Bundle

**Elective Induction Bundle**
- Reassuring Fetal Status
- Pelvic Exam prior to the start of Oxytocin
- Recognition and  management of Hyperstimulation
- Gestational Age >/= 39 weeks

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

## Vacuum Innovation Bundle

- Prepared patient
- Informed consent discussed and documented
- 	Alternative labor strategies considered
- High probability of success
- EFW, fetal position and station known
- Maximum application time and number of pop-offs predetermined
- Exit strategy available
- Cesarean and resuscitation team available

## Slide 66

## Seton Hospital Alpha SitesBirth Trauma

- Seton Hospital Alpha SitesBirth Trauma

- Mazza F, et al. Eliminating birth trauma at Ascension Health.
*Jt Comm J Qual Patient Saf *33:15-24, Jan. 2007

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## New Claims Reported

## Actuarial ProjectionsReported Claims Per 10,000 Births

## Actuarial ProjectionsOB Claim Cost per Birth