Expedition Coordinator

Transcription

1 IHI Expedition: Preventing Obstetrical Adverse Events Deb Bell-Polson, MSN, RNC-OB Peter Cherouny, MD These presenters have nothing to disclose Expedition Coordinator Kayla DeVincentis, Project Coordinator, has worked at IHI since 2009, starting as an intern in the Event Planning department. Since then, Kayla has contributed to the STAAR Initiative, the IHI Summer Immersion Program, and the IHI Expeditions. Kayla obtained her Bachelor s in Health Science from Northeastern University and brings her interest in health and wellness to IHI s Health and Fitness team. 2 1

2 WebEx Quick Reference Welcome to today s session! Please use Chat to All Participants for questions For technology issues only, please Chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text 3 When Chatting Please send your message to All Participants 4 2

3 Our Expedition Director 5 Sue Leavitt Gullo, RN, BSN, MS, Managing Director, Institute for Healthcare Improvement (IHI), brings 30 years of health care experience to her current roles, which include work in IHI's national and international patient safety work, and IHI's faculty for leadership and patient safety. She is the Director of the Perinatal Improvement Community and The Safer Patient Project in Denmark. Prior to joining IHI, Ms. Gullo was the Director of Women's Services at Elliot Hospital in New Hampshire. Her prior nursing roles included experience in the frontline clinical areas of maternal-child health, oncology, and medical-surgical nursing. Ms. Gullo has also been active as national faculty in obstetrical care for the last 15 years. Her involvement with IHI dates back to 1995 as a participant in the IHI Breakthrough Series on Improving Maternal and Neonatal Outcomes and continued as IHI faculty until she joined the IHI staff in Ground Rules We learn from one another All teach, all learn Why reinvent the wheel? - Steal shamelessly This is a transparent learning environment All ideas/feedback are welcome and encouraged! 6 3

4 Schedule of Calls Session 1 Introduction to Obstetrical Adverse Events Wednesday, May 30, 1:00 PM 2:30 PM ET Session 2 Structure and Process for System Redesign Date: Wednesday, June 13, 1:30 PM 2:30 PM ET Session 3 Executing Oxytocin Bundles Date: Wednesday, June 27, 1:30 PM 2:30 PM ET Session 4 Designing Reliable Processes Date: Wednesday, July 11, 1:30 PM 2:30 PM Session 5 Using the Perinatal Trigger Tool to Identify System Harm Date: Wednesday, July 25, 1:30 PM 2:30 PM Session 6 Results Report-out and Advanced Bundles Date: Wednesday, August 8, 1:30 PM 2:30 PM 7 Expedition Objectives At the end of the Expedition, participants will be able to: Describe two reasons to eliminate elective deliveries prior to 39 weeks confirmed gestation. Identify the components of the IHI Perinatal Care Bundles. Define reliability and give an example of components that will achieve different levels. Describe the Model for Improvement and the need for small scale testing. 8 4

5 Faculty Deb Bell-Polson, MSN, RNC-OB, is a Masters prepared Perinatal Nurse with 22 years of experience. Most recently has worked as a Clinical Nurse Manager leading a multidisciplinary team that has had great success in the IHI Perinatal Community. We had proven results in changing culture for quality and safety and achieving 95% compliance on the Elective Induction and Augmentation bundles as well as the Vacuum Bundle. Also serves on a regional Quality and Safety Network guidelines team that is working to set regional standards for care in the Northern New England region. Is most recently a part of a state wide Committee to review cases of Sudden unexplained infant Deaths and work to prevent them in the future. When not working I keep busy with my family of three sons and a wonderful husband. 9 Faculty Peter Cherouny, MD, Professor of Obstetrics and Gynecology, University of Vermont College of Medicine, has strong clinical interests in obstetric health care quality improvement and is currently serving as Chair of the Institute for Healthcare Improvement's Perinatal Improvement Community. He was also the lead author of the IHI white paper, "Idealized Design of Perinatal Care." He has been Chair of Quality Assurance and Improvement and Credentialing for the Women's Health Care Service of Fletcher Allen Heathcare for the last 15 years. His recent research and work in obstetric quality improvement is as Chair of the March of Dimes collaborative, "Improving Prenatal Care in Vermont," and as co-investigator of the MedTeams project. 10 5

6 Agenda Volunteer Report-Out The Royal Commission Medical Center IUH University Hospital How to Manage Change Obstacles and Resistance Closing and Follow-up 11 Storyboard Report-Out The Royal Commission Medical Center Dr. Nada (Obstetrician) Ms. Nabissah (L&D Nurse) 12 6

7 BACKGROUND RCMC would like to maximize the approach in overall safety in Obstetrics and Gynecology Department that would reduce the rate of adverse outcome thus improve patient safety, decrease patient injury and decrease liability losses. Through IHI Expedition, RCMC staff will initiate clinically based practices, collecting data for perinataltrigger tool and create a comprehensive and standard protocols and guidelines. 7

8 FACILITY DESCRIPTION DEMOGRAPHIC Royal Commission Medical Center (RCMC) is located in Yanbu Al- Sinaiyah, also known as The Industrial City having a 4-storey building with 361 beds capacity. The Ob-Gyne Department situated in the 1 st floor secured by all automated locked door. RCMC holds the prestigious Joint Commission International (JCI) accreditation standard. This internationally recognized standard reflects the organization s commitment to provide the highest quality patient care. SYSTEM CHARACTERISITIC Ob-Gyne Department offers a wide range maternity & newborn care such as : Pre & Post Natal Care Gynecology Newborn Referral to Medical-Surgical Professional Equipped with the highest standard of technology Investigation and treatment of recurrent Abortion Ob-Gyne Team composed of highly trained healthcare professionals, as follows: Obstetricians Anesthesiologist Neonatologist Pediatrician Nutritionist Social Workers Registered Nurses & Midwives To provide such services, they render a : 24/7 On-call Consultant Obstetric & Anesthesiologist Emergency support for potential complications Onsite Neonatal Intensive Care Unit Newborn Nursery Rooming In Maternity Clinic for out patient services Emergency Room is working round the clock THE MEETINGS.. PICTURES THE DATA COLLECTORS 8

9 Team Leader & Members Team Leader: Dr. Issam Ben Ali Acting Chief, Ob-Gyne Dept. Facilitator: Dr. Ahmed El-Gamal QI Officer Members: Dr. Mostafa Ghalwash QI Director Dr. Mohammed Eshmawi Manager, Pharmacy Dept. Dr. Basam Hejeli Senior Registrar, Ob-Gyne Dept. Dr. Nada Ahmed Registrar, Ob-Gyne Dept. Ms. Hadeel Haleem Daqeeq Nursing Instructor, Nursing Education Dept. Ms. Harjit Kaur Singh - Nursing Instructor, Nursing Education Dept. Ms. NabeesahMohammed Head Nurse, L& D Unit Ms. Marylew Deicker Pascua RN-RMW, L&D Unit Ms. Ms. Sherlly Visitacion RN1, OB-Gyne Ward Ms. Charmaine Grace Gaa-ng- RNMW, OB-Gyne Ward Mr. Yassser Al-Ghamdi Pharmacist, Pharmacy Dept. Ms. Hadeel Al-Harbi Pharmacist, Pharmacy Dept. Ms. Mary Ann Loren QI Coordinator AIM The Ob-Gyne Expedition Team initiated this quality improvement project intended to all patient and staff of Ob-Gyne Dept. to: Reduce the adverse events noted during review of trigger tool. Revised all unit protocols, policies & algorithm according to evidence based theory. Adopt the SBAR technique for communication and NICHD Terminology during documentation. Generate related forms for obtaining consent and, prescribing medication and physician s order. Ob-Gynestaff must have a regular meeting to review fetal heart rate monitoring strips. Consequently, this improvement strategy will maintain to ensure staff dedication in providing safety practices at all times. 9

10 GOAL 31 st May All members joined and participated the IHI Expedition entitled Preventing Obstetrical Adverse Events. 3 rd June 2012 The first meeting takes place; delegation of task was given to all participants; review the process in Ob-Gyne Department to identify the defect and established the areas for improvement, such as: Review of fetal monitoring strip in a weekly & monthly basis Revision of Oxytocin administration Generate a standard Physician s Order Sheet Adopt the Tachysystole Algorithm Standardize the Clinical Algorithm for management of indeterminate/abnormal FHR patterns Utilization of SBAR (Situation, Background, Assessment, Recommendation) technique for communication Generate informed consent form for Oxytocin Administration Updated statistic for induction /augmentation procedures SURVEY FORM Structure Yes No N/A % Yes 1. Interdisciplinary Fetal Monitoring Education 100% 2. Documentation tools consistent with NICHD (National Institute of Child Health and Human Development) Terminology 0% 3.Weekly fetal monitoring strip and case reviews or (#4) 0% 4. Monthly fetal monitoring strip and case reviews 0% 5. Standard mixture and policy for oxytocin administration 50% 6. One standard administration order set 0% 7. If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed 0% 8. Team definition for tachysystole 25 % 9. Clinical algorithm for identification and management of tachysystole 0% 10. Clinical algorithm for management of indeterminate/abnormal FHR pattern (NICHD 2009) 50% 11. RN empowered to call cesarean team (not to diagnose the need for cesarean, but to activate the team) 12. RN empowered to call neonatal team 100% 13. Consistent handoff tool {SBAR, etc} specify 0% 14. Informed Consent for oxytocin administration 0% 15. Individual Provider data published about induction/augmentation rates? 0% 10

11 OXYTOCIN- Elective Induction Bundle Composite Data Collection Tool Elements: Gestational Age 39 weeksor >. Documented prior to initiation of oxytocin. Per ACOG definition in ACOG Practice Bulletin Number 107, August 2009{Induction of Labor}. Team Definition: >39 weeks of Gestational Age at the time of Induction Normal Fetal Status: See NICHD September 08 Tier Recommendations. Assessed and documented prior to initiation of oxytocin and during administration. Team Definition: Fetal weight of > 2.5 and < 4.0 k and Reassuring CTG Pelvic Assessment: This element includes documentation of a complete pelvic assessment with cervical examination (dilation, effacement, station of the presenting part, cervical position and consistency; Bishop s Score), clinical pelvimetry (acceptable is adequate pelvis ) and an assessment of the fetal presentation. Team Definition: Bishop Score of > 7; Documented as adequate clinical pelvis and assessment of the fetal presentation/ position Tachysystole: Recognized and management throughout the administration of oxytocin. NICHD September 08 Definition- >5 contractions in 10 minutes, averaged over a 30 minute window. If present, it is recognized and treated. Team Definition: >5 contractions in 10 minutes, averaged over a 30 minute window Instructions: Review 5 charts each week where oxytocin was used to electively induce labor. N: Total number of individual components in place (5 charts X 4 elements= 20) D: Total number of elective induction components possible in 5 charts reviewed(20). MR # Gestational Age Score Normal Fetal Status Score Pelvic Assessment Score Tachysystole Score Total AUGMENTATION BUNDLE Chart 1 Chart 1 Chart 1 Chart 1 Chart 1 TOTAL EFW Reassuring FHR (not Category III) Pelvic Exam Tachysystole TOTAL 11

12 GESTATIONAL AGE RELIABILITY Confirmation of Term Gestation Individual Tool *Collect data on all scheduled deliveries, inductions and cesareans Current ACOG recommendations (ACOG Number 107, 2009) for determination of term gestation: Ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater. Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography. It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test result. Criteria met for scheduling elective delivery? YES NO NOT SURE Information obtained from prenatal record prenatal office staff other *If NO or NOT SURE, (next action step is a local decision) escalation policy: 1. Deny scheduling, notify Chief/Medical Director of OB for case review and approval 2. Schedule case and note as pending final approval from Chief/Medical Director of OB *Local team will want to keep data on scheduling practices in order to provide feedback and learning where needed if cases do not meet ACOG criteria. N= Number of scheduled deliveries for which there is documentation of data that is considered optimal criteria D= Total number of scheduled deliveries Report weekly the summary (N) of yes answers, and the summary of scheduled cases (D) PLAN To implement the weekly Fetal Monitoring Review among Ob-GynePhysicians (Minutes of meeting must be documented). To update the clinical guidelines for Oxytocin administration and to utilize the Informed Consent prior oxytocin administration. To develop a Clinical algorithm for identification and management of tachysystole. To monitor continuously the data concerning induction/augmentation rates. 12

13 BRAINSTORMING Team definition for OxytocinElective Induction Bundle Composite 13

14 DO Revision of Clinical Guideline for Oxytocin Administration Review of fetal monitoring strips done by the Ob- Gyne physicians in a daily and weekly basis Formatted and implemented the OxytocinConsent Form and Pre-Induction Checklist Adopted the IHI Tachysystole Algorithm Continuously data collection for Augmentation, Induction of Labor and Perinatal Trigger Tool CHECK 14

15 Table 1:NEWBORN TRIGGER TOOL Number of Newborn Delivered in RCMC Apgar Score 5 minutes Newborn Admitted to NICU Newborn Admitted to NICU > 24H Table 2: PERINATAL TRIGGER TOOL Number of Deliveries T7 T17 P5 15

16 Table 3: NUMBER OF PATIENT ADMITTED IN RCMC WITH GESTATIONAL DIABETES Series 1 Series 2 Series JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC Table 4: BLOOD UTILIZATION (PRBC) IN LABOR & DELIVERY UNIT

17 Table 5: NUMBER OF CASES OF POSTPARTUM HEMORRHAGE IMMEDIATE PPH DELAYED/SECONDARY PPH 2.5 Table 6: NUMBER NEWBORN SUFERRED FROM SHOULDER DYSTOCIA JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC 17

18 Table 7: NUMBER OF CASES RELATED TO BIRTH INJURY IOL & INDUCTION BUNDLE 120% 100% 80% 60% 40% 20% 3rd Week of June 4th week of June 1st week of July 2nd week of July 3rd week of July 4th week of July 0% Induction of Labor Augmentation 18

19 ACT Change the Structure compliance from 2 points into 8 points. Agreeing on team definitions & Policies Putting Consent in action Orienting staff Continuous Evaluation of practices TESTIMONIES Dr. Essam Bin Ali (Head of Ob-Gyne Department) Routine daily work that we thought of as Perfect, turned to have many opportunities for improvement. Dr. Nada Hussein (Registrar, Obstetrician) Perinatal Care Knowledge was there, but the project has put everything in clear frames. Dr. NaglaHussein (Resident, Obstetrician) My Impression is that this project changes practices into better ones, however, prompt implementation is still a challenge. Ms. Harjit Kaur Singh (Nursing Clinical Instructor) Awareness of such practices increase patient safety culture & makes processes more friendly & more simple; It will be incorporated in our CNE activities. Ms. Charmaine Grace Gaang(MW, OBW) Documentation of pelvis assessment needs improvement, We will do it as a TEAM. Ms. Emma Baladad(MW, L&D Unit) We practised the gestational age verification & it was a good experience. Ms. Marylew Deicker Pascua (RN, L&D Unit) I really liked that we reached Team Definitions, as we had various definitions when we started the project. It was difficult to implement the Oxytocin consent & we had some challenges with the Pelvis assessment documentation. Trigger tool initiated a scientific discussion in the department & we are willing to implement the new guidelines. Ms. Hadeel Al-Harbi (Pharmacist) Although this expedition didn t affect my practices directly, yet I learned about the IHI & managing changes. Dr. Mohammed Eshmawy (Pharmacy Manager) It was a very Educational opportunity, I learned about Oxytocin & medical practices. I think I ll use the PDCA methodology afterwards in my practice Dr. Ahmed AlGamal (Quality Improvement Officer) After the 1 st session, we measured our structure against the IHI requirements & we found that we were only complying to only 2 points, now we are almost complying with 8 points. This project really helped to build good team dynamics. Because of time difference, my colleagues used to come to the hospital on their afterhours to attend. It also enhanced the culture of using guidelines Ms. Mary Ann Loren Quality Improvement Coordinator Healthcare professionals awareness of this project is very essential for it to succeed 19

20 IHI EXPERIENCE Generally speaking. We learned that even if our practices were good, yet they were not documented. The Oxytocin Induction Consent was a really good idea that helped us to maintain patient rights & protect staff practices. Furthermore the main challenge will be is how to disseminate the information & total involvement of all Ob-Gyne Staff. CONCLUSION A scrupulous review exhibiting RCMC approach in overall safety in Obstetrics and Gynecology which focuses on measuring adverse events on Induction and Augmentation of Labor resulted to a conclusion that our procedures mostly being done in respect to the knowledge and experience of our physicians and not following the written protocol. Based on weekly Fetal Monitoring Review among Ob-GynePhysicians, we came to know that their documentations needs improvement. With weekly data collection for Induction of Labor using the Oxytocin-Elective Induction Bundle Composite, RCMC has leaped a 10% improvement from baseline 65% to 75% in one month window period. Meanwhile, Augmentation Bundle exhibited on the month of July form 60% to 100%. Each graphical representation vividly depicts data on the course of PerinatalTrigger Tools. T1 implies to newborn with Apgarof < 7 in first 5 min of life; in Table 1, 2010, 2011 and 2012, sum total of delivered newborns were 3243, 3475 and ApgarScore ranges to 26%, 25% and 25%, however newborn admission to NICU was 27%, 28% and 22% respectively. As T7 denotes 3 rd or 4 th degree lacerations while T17 entails Administration of Oxytocic Agents, Table 2, illustrates 3464 deliveries in 2011 and 1802 deliveries halfway of Figuratively, there is only a less than 1% T7 reported cases for both years. However, a colossal number of Oxytocin 65% of the latter receives >20 units after immediate postpartum period while the former were 61%. Table 4, portraying T9 for Blood Transfusion markedly doubled in numbers from 2011 to Moreover, T15 which is pertaining to Estimated Blood Loss; Table 5 there has been 24 cases of 3464 deliveries for 2011 and, 23 out of 1802 in midyear of 2012 reported. T18 Instrumented Delivery: 85 cases of instrument deliveries in 2011 and 45 instrument deliveries halfway of Gestational Diabetes as T21 shows that there are reported cases as 9% and 12% out of total deliveries for 2011 and midyear of 2012 as depicted in Table 5. Divulging on above apropos inference, RCMC has revised the Clinical Guidelines for Oxytocin Administration, formulated an Informed Consent prior to Oxytocin Administration and Pre-Induction Checklist, and adopted the Clinical Algorithm for Identification and Management of Tachysystole by the IHI. 20

21 Storyboard Report-Out Indiana University Health University Hospital Elizabeth Spoor Kerista Hansell Ginette Budreau 41 Questions? Raise your hand Use the Chat 42 21

22 Preventing OB Adverse Events Expedition Team Storyboard Team: IUH University Hospital Indiana University Health University Hospital This unit cares for obstetric patients throughout their pregnancy from antepartum complications, intrapartum and delivery, postpartum care, and bereavement care. This unit cares for acute, progressive, and critical care needs. There are three triage beds offering ER services to obstetric patients, ten L&D rooms, two operating rooms, and a PACU. The patient population is comprised of both high-risk and low-risk patients. Our unit is supported by Maternal-Fetal Medicine physicians as well as OB/GYN physicians. We are the hub of the MFM practice and approximately half of our patient population is transferred from other facilities for care deliveries per year Level 3 Special Care Nursery Part of an AHC with another delivering facility and a level 3 NICU. Part of a health system that includes 10 delivery sites 22

23 Who is on Your Team? Ginette Budreau, RN, MA, MBA - Director, Nursing Operations Betsy Spoor, RN, BSN, Clinical Nurse Manager, OBICU Kerista Hansell, RN, CNS Perinatal Clinical Nurse Specialist Lee A. Learman, MD, PhD, Medical Director, Women's Health Services IU Health University & The Indiana Clinic Men-Jean Lee, MD Chief of OB/GYN Amy Nethery, RN, BSN Nurse Safety Analyst Alexis Neal, RN Director of Women s Service Line IUH Team Survey In Progress Have need education Secondary Priority First Priority Unsure if MDs want Structure Yes No N/A 1. Interdisciplinary Fetal Monitoring Education Documentation tools consistent with NICHD terminology Weekly fetal monitoring strip and case reviews (or #4) Monthly fetal monitoring strip and case reviews Standard Mixture and policy for oxytocinadministration One standard administration order set If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed Team definitionfor tachysystole Clinical algorithmfor identification and management of tachysystole 4 4? Clinical algorithm for management of indeterminate/abnormal FHR patterns 0 7? RN empowered to call c/s team (not to diagnose, but to activate) RN empowered to call neonatal team Consistent handoff tool (SBAR, etc.) (specify: ) Informed consent for oxytocinadministration Individual providerdata published about induction/augmentation rates? % Yes 23

24 Journey to your AIM 1. Education for our team regarding processes in place (yellow rows) 2. Fine tune project in progress (green rows) 3. Benchmark against other IU Health facilities to learn about their progress/processes already in place 4. Focus on first priority rows (blue) 1. Clinical algorithm for identification and management of tachysystole 2. Clinical algorithm for management of indeterminate/abnormal FHR patterns 3. Individual Provider data published about induction/augmentation rates Does our physician team want this/find this useful?? Aim The IUH University Hospital interdisciplinary team is focused on improving communication, safety, and quality outcomes surrounding oxytocin administration. Our team intends to accomplish the following: 1. Identify and implement a clinical algorithm for identification and management of tachysystole by December Identify and implement a clinical algorithm for management of indeterminate/abnormal FHR patterns by December Explore with MD leadership whether or not there is a desire to publish individual provider data about induction/augmentation rates by December

25 Tests of Change Final Word 25

26 Questions? Raise your hand Use the Chat 51 Mindful Practice It is not enough to do your best you must know what to do and then do your best W. Edwards Deming 26

27 First Critical Step Be able to explain the WHY 53 How do we view others? Do others resist change? Or do they resist being changed? 54 27

28 How do we view others? Do others resist change? We respond by attempting to overcome that resistance to change We end up creating resistance 70% of change efforts fail 55 How do we view others? Do others resist being changed? You can t trick people into changing. Allow them control as long as the outcome is acceptable. Allow them to make decisions

29 Engaging Improvement Methods Define the outcome you want. Suggest a path to achieve it. Allow people to reject your path as long as they choose an alternate route to the same destination. Remember the Why. 57 Engaging Improvement Methods Don t sell, which requires buy-in Identify and raise disagreement Allowing changes creates accountability 58 29

30 Engaging Improvement Methods Self motivation Energized alignment Inspired collaboration vs micromanaged vs passive resistance vs frustrating exhaustion Engaging Improvement Methods 1. Standardize what is standardizable, no more. 2. Generate light, not heat, with data (use data sensibly and use it for learning not judgment) 3. Make the right thing easy to try. End paralysis by analysis 4. Make the right thing easy to do. 30

31 Attributes of the Change Relative advantage - compared to current method (evidence from testing) Compatibility - with the current system and current values Simplicity - both the change and transition Trialability - how easy is it to test the change Observability - ability to observe the change and its impact Adopter Categorization on the Basis of Innovativeness 2.5% Early Adopters 13.5% Early Majority 34% Late Majority 34% Laggards 16% - 2sd - 1sd 0 + 1sd 31

32 Matching Activities to Key Adopter Categories Early adopters -Search for successful sites -Create pull through communication -Change agents need a plan for sites that come forward -Focus on influencers as messengers -Make the work of early adopters observable Early majority -Allow for peer-to-peer contact with early adopters -Communicate local successes Late majority -Peer pressure is necessary -Communicate adoption of the changes is inevitable Try and Get People to Test Make it less frightening Allows people to try it on Legitimizes feedback 64 32

33 Usual Responses There is no problem - share data The change won t work - share results The change isn t valid - share science You don t understand my work - have a colleague speak with them I don t have time - very small test 65 Questions? Raise your hand Use the Chat 66 33

34 Follow up The listserv will remain active. To use the listserv, address an to A manual with instructions to receive Continuing Education Credits will be sent with the follow-up for today's session. Please take 5 minutes to complete the Expedition evaluation survey. Coming Soon! How-To Guide: Prevent Obstetrical Adverse Events 68 34

35 Thank you! 35