Forging High Reliability in Perinatal Care: The Premier Perinatal Patient Safety Initiative

Transcription

1 Forging High Reliability in Perinatal Care: The Premier Perinatal Patient Safety Initiative Gwen Stokes, BSN, MPH, CPHQ, CPHRM Kathy Connolly, BSN, MSEd, CPHRM Why did Premier decide a Perinatal Safety Initiative was important? Birth Trauma: Low Frequency BUT High Severity Problem A blind spot to the need for quality improvement may arise due to the low number of adverse outcomes* 5 birth related injuries per 1,000 births 1 bad brachial plexus injury per 33 years of practice (assuming 140 deliveries per year by physician) 1 hypoxia-related case of Cerebral Palsy per 48 years Even one birth related injury or death has significant impact on all involved. Parents and families Clinical care providers Legal consequences Insurers Public assistance resources *Journal of Maternal-Fetal and Neonatal Medicine :203

2 Perinatal litigation facts Over 50% of a typical hospital s budget for risk management is spent in the Labor and Delivery area The #1 most frequent allegation in perinatal malpractice claims is delayed diagnosis of fetal distress which is monitored via EFM Over half of liability claims against physicians were obstetric and almost half of those (46%), EFM was a variable In 75% of birth-related lawsuits, the award or settlement is over $1 million OB claim impact on physicians 2009 ACOG Poll finds litigation impact on OBs alarming Average age to quit obstetrics-48 59% changed practice in some way due to insurance issues 90.5% of respondents had 1 claim filed; average-2.69 claims 63% changed/reduced practice due to liability concerns 19.5% increased cesarean section rates 21.5% decreased number of high risk deliveries 19.5% stopped offering/performing VBACs 10.4% decreased deliveries 6.5% stopped obstetrics OB claim impact on physicians OB claim payments and costs continue to rise* $137 million paid for OB claims in just 2007 with over $3 billion paid for claims from Of all medical specialties OB had the highest percentage of claims closed with payments % of all specialty claims Almost half (49.4%) of all brain damaged infant claims closed with an indemnity payment OB/GYN closed claims from for brain damaged infants had an average payment of $565,152 OB/GYN closed claims in just 2007 for brain damaged infants had an average payment of $688,600 *Physician Insurers Association of America (PIAA) Data Sharing Study 2008

3 Reductions in Harm Recent studies report improvements in OB outcomes HCA (2008) reported improved patient outcomes, reduced litigation and a lower primary cesarean section rate Intermountain Healthcare (2009) reported it reduced the incidence of elective deliveries before 39 weeks gestation from 28% to less than 3%and saw a reduction in complications and injuries to newborns including NICU admissions. Yale New Haven Hospital (2009) reported a significant reduction in the Adverse Outcome Index (10 obstetrics - specific adverse outcomes) and clinically significant improvements in safety climate/culture Magee Women s Hospital of UPMC (2009) reported the percentage of elective inductions before 39 weeks of gestation dropped from 11.8% to 4.3%, a decrease of 64% (P<.001) after implementing a 39 week elective induction rule.. 7 If 99.95% were good enough. 44 newborns would experience significant birth trauma within the Seton Healthcare Network annually - Dr. Gary Pfeiffer The #1 Reason This is the way it is supposed to be!

4 What is a High Reliability Organization (HRO)? Organizations with systems in place that are exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors McKeon LM, Oswaks, JD, Cunningham PD. Safeguarding patients: Complexity science, high reliability organizations, and implications for team training in healthcare. Clinical Nurse Specialists, 2006 Nov-Dec: 20(6): Common characteristics of organizations where high reliability is important Hyper complexity Tight Coupling Extreme Hierarchical Differentiation Multiple Decision Makers In a Complex Communication Network High Degree of Accountability Require Frequent, Immediate Feedback Working Under Compressed Time Constraints Premier is helping hospitals build High Reliability perinatal teams and services Characteristics of high reliability perinatal teams*: An organizational culture where patient safety is promoted, supported and understood throughout the organization Strong interdisciplinary leadership Professional team interaction that promotes the communication of important patient information and expedites the prompt delivery of medical attention during emergencies Multidisciplinary rehearsal of emergencies Adoption of common language to describe fetal well-being during labor among all healthcare providers Policies and procedures which are supported by national professional standards, evidence-based medicine and best practices supporting patient safety Standardization and simplification of clinical protocols and unit operations *Selected concepts based on research from: [1] G. Eric Knox, MD, Kathleen Rice Simpson, Ph.D., RNC, FAAN and Kathryn Eblen Townsend, JD, RN, ARM, High Reliability Perinatal Units: Further Observations and A Suggested Plan for Action, ASHRM Journal, Fall 2003, pg [2] Barbara J. Youngberg, BSN, MSW, JD, FASHRM, Assessing Your Organization s Potential to Become a High Reliability Organization, ASHRM Journal 2004, Vol. 24,No.3, pg

5 Objectives of the Premier Perinatal Safety Initiative The 21-month Collaborative is helping the participating hospitals: Consistently implement best practices designed to improve the reliability of perinatal care Develop high reliability perinatal healthcare teams Improve and measure clinical outcomes and patient satisfaction in labor and delivery Lower the cost of perinatal care and potential liability exposures Reduce birth trauma and maternal trauma Obtain measurable improvement in staff culture of safety Leverage the knowledge gained through the Premier/IHI Perinatal Collaborative of , and other similar initiatives January st Quarter Hospitals 12 States Teaching & Non-teaching hospitals 115,000 deliveries Participating hospitals in the current Initiative Arizona -John C. Lincoln North Mountain Hospital, John C. Lincoln Health Network (Phoenix, AZ) Illinois -Methodist Medical Center of Illinois (Peoria, IL) Kentucky -Baptist Hospital East, Baptist Healthcare System (Louisville, KY) Massachusetts -Baystate Medical Center, Baystate Health (Springfield, MA) Minnesota -Fairview Ridges Hospital, Fairview Health Services (Burnsville, MN) -Univ. of Minnesota Medical Center, Fairview, Fairview Health Services (Minneapolis, MN) New Mexico -Presbyterian Hospital, Presbyterian Healthcare Services (Albuquerque, NM) Ohio -Bethesda North Hospital, TriHealth (Cincinnati, OH) Ohio (continued) -Good Samaritan Hospital, TriHealth (Cincinnati, OH) -Summa Health System, Akron City Hospital (Akron, OH) Tennessee -Indian Path Medical Center, Mountain States Health Alliance (Kingsport, TN) Texas -Texas Health Harris Methodist Fort Worth Hospital (Forth Worth, TX) -Texas Health Presbyterian Hospital of Dallas (Dallas, TX) Washington -St. Joseph Hospital, PeaceHealth (Bellingham, WA) West Virginia -City Hospital, West Virginia University Hospitals (Martinsburg, WV) Wisconsin -West Allis Memorial Medical Center, Aurora Health Care (West Allis, WI)

6 Comprehensive assessment reports Each participating hospital received two sets of printed reports and a DVD with all the various report sections Each report contained results of: AHRQ Culture of Safety Survey High Reliability Perinatal Services Risk Assessment Obstetrical and Perinatal Services Clinical Technology Evaluation Supply Chain Evaluation and Savings Report AHRQ Culture of Safety Survey Premier Perinatal Safety Initiative Baseline Culture of Safety Comparisons All Participating Hospitals Means to AHRQ OB Only Means 85% 75% 65% 55% 45% Intervention Group Mean A HRQ Nat'l Mean - OB ONLY Hospital Handoffs & Transitions Teamwork Across Hospital Units Staffing Hospital Management Support for Patient Safety Nonpunitive Response to Error Feedback & Communication About Error Teamwork Within Units Organizational Learning-Continuous Improvement Frequency of Events Reported Supervisor/Manager Expectations & Actions Promoting Patient Safety Overall Perceptions of Safety 25% Communication Openness 35%

7 High reliability assessment scorecard Sections of the culture of safety survey where opportunities for improvement were identified: Overall Perception of Safety Frequency of Events Reported Supervisor/Manager Expectations & Actions Promoting Patient Safety Communication Openness Feedback & Communication About Error Teamwork across hospital units Non- punitive Response to Error Hospital Handoffs and Transitions Clinical technology assessment findings Fetal Monitors New generation of products just released Most hospitals should replace within the next 5 years OB Data Management & Decision Support System Many hospitals will upgrade or replace their OBDMS within the next 5 years Most hospitals do not have a decision support system Vacuum Extractors Hospitals have converted to completely disposable systems Single use per birth Infant Incubators & Warmers Most hospitals have notably aging units that should be replaced within the next 5 years Newborn Hearing Screening Systems Some hospitals are outsourcing this function

8 Supply chain assessment: detailed savings opportunities per delivery D eliveries 2650 Hospit al ABC Logo Vag deliveries 2000 Supply Description Com ment /O pportunity C-Sections 650 Total savings $122, Savings/delivery $46.08 Hospital ABC Current p rice New Price Savings Notes CB C a nd typ e and ho ld dra wn on e ve ry p atient on adm ission. 55 % of the facilities p articipating in th is initiative do not do routine Admission Labs type an d hold. Discontinue routine type an d hold - draw la bs only as patient conditio n dictates - e.g schedule d c-se ctio n $4.00 $0.00 $7,200 IC Foleys Discontin ue usage of IC Fo leys. Curren tly usin g Tyco Dover Silver with a tota l volume of 996 an d an average each price of $ Suggest chan ge to Bard or Tyco equivalent for s ho rt-te rm ca th s. Pricin g fr om Bard co ntract # PP- NS -409, $7.7 8 each. $ $7.78 $2,898 Epidural Tra y Consider changing to a stan dard e pidu ral kit. Current kit avera ges $ each. P rem ie r co ntracts h ave prices va rying from $10 to $26. $31.20 $26.00 $ 5,720 C urre ntly usin g Hollister Am nihoo k a t $1.5 5 each. Reco mm ed switch to DeRoyal Othe r facilities h ave gotten price s as Am niotic Perforator low as $0.84 for the DeRoyal Am niho ok. Neithe r p roducts on Pre m ier contract. $1.55 $0.84 $ 1,562 Cervical Ripening Agents Currently u se Ce rvidil (Dino prostone ), P repidil and P rostin. Recommend considering use of Cytotec (Miso prostol). Misoprostol has much the same mechanism of action, benefits, complications, indications, adverse reactions and co ntraindications as other cer Dinoprostone $19.06 Misoprostol $0.32 $47,3 08 Premier Perinatal Safety Initiative Suply Chain Assessment Results Hospital Total Annual Savings Savings/delivery Deliveries A ND* B ND* C $195, $ D ND* E ND* F $138, $ G $62, $ H $161, $ I $31, $ J $122, $ K $123, $ L ND* M ND* N $212, $ O $90, $ P $96, $ Q $30, $ Total $1,266, Average $115, $ Savings identified for 11 Hospitals ranged from $30, to $212,671 in annual savings key ND* Assessment not done as PCS had performed in a separate PCS engagement in past 18 months April 2008 conference with all hospital teams focused on team communication and teamwork using SBAR and In Situ Simulation

9 Learning and knowledge transfer during the Initiative Two education conferences with each hospital represented by a team of six healthcare professionals to include their physician leader Topics covered during these conferences included: Team communication using SBAR, a structured communication technique. OB case studies where teams practiced this communication method thru role playing situations Emergency simulation drills how to set up, what equipment to use, briefing staff before the simulation, holding a debriefing after the simulation and best practices learned from OB simulation training Discussion of best practices and emerging evidence-based care Sharing team findings and strategies for clinical process changes Monthly webinars provide education on best practice information sharing Healthcare clinicians, acting as faculty, provide ongoing support and help Team Communication Improvements Each hospital was encouraged to use SBAR communication technique Huddles during shifts Debriefings after events Common language for fetal monitoring Fetal Monitoring Use of NICHD terminology September 2008 ACOG and AWHONN jointly adopt the NICHD terminology for Fetal Heart Rate Monitoring Hyperstimulation and hypercontractility dropped now use Tachysystole Three tier Fetal Heart Rate Interpretation System (Category I, Category II, Category III) Physician and Nurse training needed to adopt this change in terminology Provided each hospital team with 10 user licenses to a web based Advance Fetal Monitor and Assessment training program that was updated to include the changes in terminology 140 user licenses issued 57 completed (after ten months 22 physicians, 2 nurse midwives and 33 nurses) CMEs and CEUs awarded to those who complete the 7 module course 42 additional user licenses purchased by hospitals for physicians, nurse midwives, and nurses

10 Process Measures of the Initiative Quality Care in Obstetrics Addressing Harm Using Bundles The Bundle Science What is it? Individual components supported by evidence based medicine/professional guidelines Required to be performed for every patient, every time Bundle compliance measured by fulfilling all parts of the bundle (all elements present or no credit for bundle) Focused on achieving consistency and reliability in clinical processes

11 Working Towards 100% Bundle Compliance With Every Patient Elective Induction Gestational age greater than or equal to 39 weeks Normal fetal status (per NICHD tiers Pelvic exam prior to the start of Oxytocin Recognition and management of tachysystole Augmentation Documentation of estimated fetal weight Normal fetal status (per NICHD tiers) Pelvic exam prior to the start of Oxytocin Recognition and management of tachysystole Vacuum Alternative labor strategies considered Prepared patient High probability of success Maximum application time and number of pop-offs predetermined Cesarean and resuscitation teams available Why standardization can improve patient safety? Contributes to building an infrastructure (who does what, when, where, how and with what) Supports training and competency testing to sustain the process Helps achieve front line articulation of key processes by staff Allows the appropriate application of Evidence Based Medicine consistently Process Measures Monthly chart audits 20 randomly selected charts of elective induction patients and 20 charts of augmentation patients Review each record looking for compliance with all four elements of each bundle No credit unless all elements of the bundle have been met Monthly chart audits for vacuum deliveries either 20 randomly selected charts or all vacuum deliveries if less than 20 vacuum deliveries that month Review each record looking for compliance with all elements of the vacuum bundle No credit unless all elements of the bundle have been met

12 Bundle Compliance Percentage Baseline March '08 Baseline April '08 Baseline May '08 E le c tiv e In d u c tio n B u n d le C o m p lia n c e A ll Hospitals June '08 July '08 Aug '08 Sept '08 Oct '08 Nov '08 Dec '08 Jan '09 Feb '09 March '09 April '09 May '09 June '09 July '09 August '09 Actual Average All Hospitals Month Linear (Actual Average All Hospitals ) Bundle Compliance Percentage Baseline April '08 Baseline M ay '08 Augmentation Bundle Compliance Average of All Hospitals June '08 July '08 Aug '08 Sept '08 Oct '08 Nov '08 Dec '08 Jan '09 Feb '09 March '09 April '09 May '09 June '09 July '09 August '09 Actual Average of All Hospitals Month Linear (Actual Average of All Hospitals ) V acuum Bundle Compliance A ll H ospitals Bundle Compliance Percentage Dec '08 Jan '09 Feb '09 March '09 April '0 9 May '09 June '09 Month July '09 August '09 Actual Average All Hospitals Linear (Actual Average All Hospitals)

13 The teams in our project should be working to become highreliability teams and trying to get to the next level of performance Look at each component of the bundle Rapid Cycle Tests of Change PDSA cycles Cycle II Cycle III Plan Do Act Study Cycle I Plan Do Act Study Plan Act Do Study P = Plan: what you want, what questions need answering, who will do it, when, how, where, how long D = Do: carry out the test as designed S = Study: what did you learn A = Act: what will you do now: adopt, adapt or abandon the change

14 Spreading a * *HTG Holding The Gains Levels of Reliability Reliability Success Rate Failures in 10, %-95% %-99.5% % % % > <.1 The road to bundle compliance improvement Reliability means bringing the right care to the right patient every time by designing and building the right system You cannot keep reviewing charts and hope that things change Education, and re-education, is only one step in a solution, it will not get you to the next level of the reliability scale

15 Level 1 (10-1, 80-95% success): Intent, Vigilance and Hard Work Design Concepts Awareness and training ( education) Common equipment (and other structural standardization) Standard orders sheets Personal check lists Feedback of information on compliance Level 2 (10-2, % success): Design Concepts shaped by reliability science and research in human factors Standardization of processes Building decision aids and reminders into the system Taking advantage of existing habits and patterns Making the desired action the default (based on evidence, e.g. constraints, forcing functions) Creating redundancy Scheduling using proper operations theory Hospital teams are encouraged to use the following techniques to improve bundle compliance: Scheduling used in design development Decision aids and reminders built into the system (Identification triggers) Desired action the default (based on scientific evidence) Habits and patterns known and taken advantage of in the design Standardization of process based on clear specification and articulation is the norm use of Protocols/Guidelines and Algorithms i.e., Oxytocin Administration Protocol Redundant processes utilized Order sets with Bundle Elements

16 Induction Checklist for Scheduling Prompts/Reminders for Bundle Elements in electronic record documentation system Tool for Operative Vaginal Delivery

17 Tachysystole addressed with Oxytocin Algorithm Harm Data Measures For the Initiative O U T C O M E M E A S U R E S A d v e rs e O u tco m e Ind e x (AO I, W A O S, S I) A H R Q P a tien t S a fe ty In d ic a tor (P S I) S e t B irth T ra u m a /In ju ry (P S I 1 7 ) C o m p lica tio n o f A n e s th e sia (P S I 1 ) F o re ig n b o d y a cc id e n t a lly le ft d u rin g p ro c e d u re (P S I 5 ) S e le c te d In fe ct io n s (P S I 7 ) T ra n s fu sio n R e a c tio n (P S I 1 6 ) H ypertension Com plicating pregnancy, childbirth, and the puerperium C onvulsions in N ew Born New Born Respiratory Problem s After Birth C N S C o m p lic a tion (N e w B o rn) Infantile C erebral Palsy O ther Newborn R espiratory Problem s After Birth Intrauterine hypoxia & birth asphyxia FROM : Birth Record B irth W eig h t A p g ar S c ore G estational Age

18 Harm or Outcome Measures Monitored Harm Measures - the Adverse Outcome Index (AOI) and several AHRQ Patient Safety Indicators (PSI) 14 of the 16 hospitals reporting have seen an improvement in their AOI score (reduction of harm) for three quarters since they began this Initiative compared to their baseline data Consists of ten adverse outcomes six are maternal adverse events and four are newborn adverse events Maternal death Birth trauma* Uterine rupture Admission to NICU >2500g & for Return to OR / labor & delivery >24hours 3º or 4º perineal tear APGAR <7 at 5 minutes Maternal admission to ICU Intrapartum & neonatal death >2500g Blood transfusion 11 of 16 hospitals reporting a reduction in Birth Trauma (PSI 17) thru three quarters of data collection compared to their Initiative baseline data *Defined differently than the AHRQ Birth Trauma Patient Safety Indicator What the hospitals are doing with their quarterly harm measures reports Looking at coding and questioning data Added coding staff to the project team Conducted training programs for physicians Using reports to ensure all adverse cases identified are peer reviewed Summarizing overall results/scores with OB multidisciplinary staff and noting trends Reporting out to hospital leadership on Initiative Progress some hospitals have established Zero Birth Injury goals for their hospital/system

19 Lessons learned so far Key Players - A dedicated oversight team for the initiative is needed with executive sponsorship Traction to meet goals requires strong team leadership and commitment to the goal of perinatal patient safety Physician/RN/Staff buy-in is essential to behavior change to meet goals (front line staff from all shifts need to be engaged in this work) 1-on-1 work with MDs facilitates behavior change however you must have a physician champion/leader Project leader that takes ownership of the project Physician champion is essential Nurse educator or clinical specialist for training SBAR, EFM and simulation drills Lessons learned so far Key steps Education, data, more data and published studies drive logical and persuasive solutions Getting physicians to agree to one protocol for oyctocin administration takes time Being an Initiative participating hospital and trying to teach/lead other non-participating hospitals in your healthcare system has its challenges and can slow down your hospital s rate of improvement Obtaining the needed administrative data for the harm measures has its challenges too and is not always easier to obtain than doing chart audits Lessons learned so far.. Outcomes achieved to date Increased sense of team and mind set changes, improved staff satisfaction, and improved multidisciplinary efforts to promote patient safety Improved medical record documentation of patient care Improved bundle compliance by all teams 13 hospitals have seen a reduction in their AOI score over four quarters compared to their baseline score All 16 hospitals conducting simulation drills

20 "Safer Care is achieved when all three- not just one- of the following are realized: summarize and simplify what to do; measure and provide feedback on outcomes; and improve culture by building expectations of performance standards into work processes." The Lancet, Volume 374, Issue 9688 pages , 8 August 2009 "Reality check for checklists" Charles L. Bosk, Mary Dixon-Woods, Christine A. Goeschel, Peter J Provonost Questions? Key Contact From Premier For any questions or additional information regarding the Perinatal Safety Initiative please contact: Project Director Kathy Connolly, BSN, MSEd, CPHRM Principal Premier Consulting Solutions kathy_connolly@premierinc.com

21 Appendix Additional Resource Information Assessment of each hospital On-site assessment of the Labor and Delivery Unit by a multidisciplinary team of professionals Risk Management Consultant from PIMS Project Manager from PCS Consultant for Supply Chain area from PCS Consultant for Technology/Equipment assessment from PCS Establish baseline data and status of hospital s safety efforts in the Labor and Delivery area to include AHRQ Culture of Safety assessment Review of clinical processes in place Discussions about current and previous safety and clinical improvement efforts Feedback includes various scorecards for each hospital Additional resources for participating hospitals Web-based fetal heart monitoring training program for physicians and nursing staff with CMEs and CEUs (HealthStream) Expert physician and nursing faculty to respond to clinical questions and discussions Quarterly team performance reports to hospital leadership Dedicated community website for tracking hospital initiative progress, communicating across participant teams, sharing resources, and accessing subject-matter experts/faculty (Wiki platform site built by Premier CITS with input from PCS and PIMS) Quarterly reports to each team that contain an analysis of submitted administrative data for AHRQ Patient Safety Indicators, Adverse Outcome Index measures, and related clinical data

22 Current Premier Initiative timeline January-April 2008 conduct on-site assessments and establish data collection for baseline measures February April register team members in project community site February April 2008-begin baseline data collection with NPIC April 1-2, st All Team Learning Session (Dallas, TX) May 2008 launch of monthly initiative webinar meetings (2 nd Thursday of each month) each month thru December 2009 June 2008-begin collection of current data to measure improvement October 23-24, nd All Team Learning Session (Dallas, TX) November 2008 thru December 2009-provide ongoing support of teams in process improvement efforts, and assistance in spreading knowledge to all staff while still collecting data Continue to collect monthly data from teams thru December 2009 April-May 2010-draft report of aggregated results Birth Trauma as defined for the AOI Measure In born infants only and diagnosis of Subdural and Cerebral Hemorrhage (due to trauma or to intrapartum anoxia or hypoxia) Epicranial subaponeurotic hemorrhage (massive) Oct Injuries to skeleton (excludes clavicle) Injury to spine and spinal cord Facial nerve Injury Injury to brachial plexus* Other cranial and peripheral nerve injuries * Not used in AHRQ PSI 17 measure for Birth Trauma Infant Birth Trauma as defined by the AHRQ PSI 17 Birth Trauma Infant Subdural and Cerebral Hemorrhage (due to trauma or to intrapartum anoxia or hypoxia) Epicranial subaponeurotic hemorrhage (massive) (added to measure in Oct 03) Injuries to skeleton (excludes clavicle) Injury to spine and spinal cord Facial Nerve Injury Other cranial and peripheral nerve injuries Other specified birth trauma* *Not used in AOI Birth Trauma Measure

23 AHRQ Patient Safety Indicator (PSI) 17 - Birth Trauma Numerator Discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code for birth trauma in any diagnosis field (see next slide for list of Birth Trauma diagnosis codes 767) Exclude infants With any diagnosis code of pre-term infant (denoting birth weight of less than 2,000 grams) With any diagnosis code of osteogenesis imperfecta (756.51) With any diagnosis code of injury to brachial plexus (767.6) Adverse Outcomes Index Index Measures Weighted Score Maternal death 750 Intrapartum & neonatal death >2500g 400 Uterine rupture 100 Maternal admission to ICU 65 Birth trauma 60 Return to OR / labor & delivery 40 Admission to NICU >2500g & for >24hours 35 APGAR <7 at 5 minutes 25 Blood transfusion 20 3º or 4º perineal tear 5 Three Adverse Outcome Index Measures I. Adverse Outcome Index (AOI) - # patients with one or more adverse events / total number of deliveries II. III. Weighted Adverse Outcome Score (WAOS)- total weights/ total number of deliveries Severity Index (SI) total weights/ # of patients with one or more adverse events

24 Additional Resources/References Agency for Healthcare Research and Quality (AHRQ ). Patient safety culture survey. Clark, S.L., Miller, D.D., Belfort, M.A., et al. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics & Gynecology 200:156.e1-156.e4. Various project related items at to include Institute for Healthcare Improvement (2005), Idealized design of perinatal care, IHI Innovation Series white paper, Boston, MA. Joch, A. (2008). New era of preventing birth-related deaths. Materials Management in Healthcare, Vol 17 No 7. from Knox, G.E., Simpson, K.R., Garite, T.J. (1999). High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims. Journal of Healthcare Risk Management, 19(2):24-32, Spring Knox, G.E., Simpson, K.R., and Townsend, K.E., (2003). High reliability perinatal units: further observations and suggested paln for action. Journal of Healthcare Risk Management, 23(3) Additional Resources/References (cont d) Macones, G.A., Hankins, G.D.V., Spong, C.Y., Hauth, J., Moore, T. (2008). The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring Interpretation, and Research Guidelines. Obstetrics & Gynecology, Vol. 112, No. 3, September 2008, Mazza,F.et al. (2007). Eliminating birth trauma at Ascension Health. Journal on Quality and Patient Safety, 33(6) Miller, K. et al. (2008). In Situ Simulation A Method of Experiential Learning to Promote Safety and Team Behavior. Journal of Perinatal Neonatal Nursing, Vol. 22, No. 2, Nielsen, P., et al. (2007). Effects of Teamwork Training on Adverse Outcomes and Process of Care in Labor and Delivery. Obstetrics and Gynecology, Vol. 109, No. 1, January 2007, Simpson, K.R. and Knox, G.E., (2008). Essential criteria to promote safe care during labor and birth. AWHONN Lifelines, 8 (6), Premier Perinatal Safety Initiative website Additional References related to AOI Measure Lessons learned from the cock-pit: How team training can reduce errors on L & D, S Mann, MD, Ronald Marcus, MD et al. Contemporary OBGYN, January 2006 Effects of Teamwork Training on Adverse Outcomes and Process of Care in Labor and Delivery, P E Nielsen, MD, MB Goldman, ScD et al. Obstetrics and Gynecology, Vol. 109, No. 1, January, 2007 Impact of CRM-Based Team Training on Obstetric Outcomes and Clinicians Patient Safety Attitudes, SD Pratt, MD. S Mann, MD, et al The Joint Commission Journal on Quality and Safety, December 2007 Volume 33 Number 12 Impact of a comprehensive patient safety strategy on obstetric adverse events, CM Pettker, MD, SF Thung, MD et al. American Journal of Obstetrics and Gynecology, published online 02 March 2009