Response to Recommendations in Report: System Review of Tertiary Obstetric Services at the Victoria General Hospital A report commissioned by the Vancouver Island Health Authority The System Review of Tertiary Obstetric Services at Victoria General Hospital was commissioned by the Vancouver Island Health Authority in August 2011. The review was an external, independent, third party review carried out by Dr. Ward Flemons MD, FRCPC, Professor of Medicine, University of Calgary, Dr. Jan Davies MD, FRCPC, Professor of Anesthesia, University of Calgary, Dr. Ian Lange, Professor of Obstetrics and Gynecology, University of Calgary and Ms. Mary John BN, MN, Manager, Antepartum, Labour & Delivery and Postpartum, Foothills Medical Centre. The review contained 21 recommendations. The reviewers organized these recommendations to follow the framework of patient safety/quality topics based on the Healthcare Encounter Safety and Quality Model which has five major elements: 1. Design healthcare delivery to achieve optimal outcomes; 2. Deliver optimal care; 3. Respond when healthcare delivery and outcomes are not optimal; 4. Leadership; and 5. Principles. The table on the following pages lists the 21 recommendations and the status of the implementation of each of these recommendations, updated as of July 2012. VIHA accepted all the recommendations. The responses and related actions will continue to be updated to reflect progress.
RECOMMENDATION: Design Tertiary Maternal Fetal Care at the VGH to achieve optimal outcomes Recommendation 1 VIHA s Population and Community Health portfolio should lead the creation of a visionary, tertiary-level, Maternal Fetal Healthcare Program (MFHP). Such a program should describe the optimal tertiary model of care that would best fit with Victoria s unique features, including the physical space requirements for such a program to thrive. A multidisciplinary team that includes patient representation should be charged with developing an appropriate model of care. The vision should include an enhanced academic focus; thus discussions should include the University of British Columbia (UBC) and other appropriate educational institutions in the province. The vision could include a major capital fund-raising campaign to provide funds that would allow needed expansion of space. VIHA RESPONSE & ACTIONS: A planning process for perinatal and pediatric services was initiated by VIHA in May 2011. The purpose of this process is to look at the service delivery model for women s and children s services at Victoria General Hospital and Queen Alexandra Centre for Children s Health. The initial phase includes a review of current service models. This will be followed by visioning and service model planning. A perinatal planning retreat took place on September 16 th, 2011 and was attended by physicians, administrators and perinatal experts. The purpose of the meeting was to improve relationships and support collaborative improvements, including identifying a common vision. The process will be expanded to include patients and representation from UBC. Discussions are ongoing and a target date for completion has been set for June 30, 2013. VIHA is working with Perinatal Services BC to complete the vision and model of care. The program will be designed in conjunction with recommendations from a Functional Review of VGH services. A multidisciplinary committee is meeting monthly with the goals to develop a system around multidisciplinary care planning for antepartum patients and high risk outpatients and to define levels of care for pregnant women in a framework that includes primary care (both family practice and midwifery), obstetrical consultation,
RECOMMENDATION: Recommendation 2 The model of care delivery should focus on the proactive management of antepartum and intrapartum risks to mother and child by: 1) defining risk factors that categorize patients within certain risk profiles (This should be done in conjunction with Perinatal BC so that provincial standards can be established); 2) assigning responsibility to the most appropriate healthcare provider (or team of providers) based on the number and severity of risks to maternal / fetal wellbeing that a patient has (This should include primary obstetrical care being provided for highest risk patients by Obstetricians / Perinatologists); and 3) developing a multidisciplinary team approach for managing the highest risk patients. VIHA RESPONSE & ACTIONS: and perinatologist consultation. As referenced in VIHA s response to recommendation 1, a planning process for perinatal services is currently underway. The emphasis is on providing more coordinated services with the goal of improving both the patient and provider experience. A multidisciplinary working group has been formed and a team approach for managing high risk patients has been developed. Risk factors that existed in a paper-based format are moving to an electronic system. Competencies required for obstetric practice for Family Practice, Midwifery and Nursing will be completed mid 2012 and a documented team based system of education to support competencies is underway. Recommendation 3 VIHA s Population and Community Health portfolio should work closely with the Department of Family Practice and with midwives to ensure the continued viability of a very strong and important part of the current model of obstetric care in Victoria. This part of the model should be retained and strengthened, capitalizing on future opportunities for training undergraduate and postgraduate students in obstetrical practice. Recommendation 4 VIHA s Population and Community Health portfolio should establish a dedicated obstetrical anesthesia (DOBA) service that functions within the current Department of Anesthesia as soon as Strengthening the South Island Obstetrical group of the Department of Family Practice and the Department of Midwifery are priority areas for VIHA. The perinatal planning process includes elements to sustain these services and the development of a Maternity Clinic at Victoria General Hospital. The Family Practice South Island Obstetrics Group is actively involved in teaching medical students. VIHA is working with the Island Medical Program on expanding teaching by this group. Planning for a Collaborative Maternity Clinic is underway. COMPLETED A dedicated obstetrical anesthesia (DOBA) service was approved and accepted by the Department of Anesthesiology in late 2011 and the anesthesia manpower plan has been updated to reflect this. DOBA was implemented in April
RECOMMENDATION: possible. Priority should be given to candidates with specialized training in obstetric anesthesia. Recommendation 5 VIHA s Chief Medical Officer and Chief Executive Officer should work expediently with PHSA and the Ministry of Health to establish the principle of equitable payment for the DOBA service as part of a provincial strategy for the provision of tertiary level obstetric care in British Columbia. The Department of Anesthesia and the Health Authority Medical Advisory Committee should be kept regularly apprised of their efforts on this file. Recommendation 6 VIHA s Population and Community Health portfolio, working with the Office of the CMO and Department Heads, should update existing manpower plans for Obstetrics, Anesthesia, Pediatrics, Neonatology, Family Practice and Midwives to support the MFHP. This should be accompanied by a plan for appropriate levels of nursing and allied health staffing to support the MFHP. Recommendation 7 VIHA s Population and Community Health portfolio working with the Office of the CMO, the Department of Obstetrics and Gynecology, and UBC should recruit an academic Head of Obstetrics. The position should be given appropriate authority (including budget) and structured to allow for additional recruitment so that a focus of expertise can be developed in the multidisciplinary management of high-risk obstetrical patients. 2012. VIHA RESPONSE & ACTIONS: See also VIHA s response to recommendation number 5. COMPLETED VIHA s executive leadership worked with their provincial counterparts and the Ministry of Health to establish the principles for compensation for a DOBA service that is equitable for similar services throughout the province and kept the Department of Anesthesiology and the VIHA Health Authority Medical Advisory Committee (HAMAC) apprised of this work. The anesthesia physician resource plan has been updated with regards to the establishment of a dedicated obstetrical anesthesia service. Other human resources plans will be updated upon completion of the model of care work (recommendation number 2); this will be completed by March 31, 2013. Recruitment is underway for an academic Department Head of Obstetrics and Gynecology. This position will be a joint appointment with the UBC Department of Obstetrics and Gynecology. A preferred candidate has been identified; subject to satisfactory arrangements being reached, the new Head of Department will assume the duties in the late summer or early fall. The new Department Head of Obstetrics will co-lead the management of the Obstetrical program with an administrative lead. These positions will jointly have responsibility for overseeing the program budget.
RECOMMENDATION: Recommendation 8 The Executive Medical Director and Executive Director, Quality & Patient Safety should work with the MFHP to design and develop appropriate performance measures for the clinical Microsystems that deliver care to mothers and neonates. These performance measures would ideally be available electronically and be tracked over time as a key piece of a safety and quality management system. Delivery of Optimal Care Recommendation 9 The Director of Child, Youth and Family Health and the Manager of LDR should take necessary steps to ensure that an appropriate number of LDR nurses are trained in all aspects of obstetrical surgical care such that the LDR can function independently of the Main Operating Room. Recommendation 10 The Executive Medical Director, Population and Community Health, should complete an audit of all physicians and midwives with obstetric privileges (and midwives) at VGH to ensure training in Fetal Health Surveillance is current and has been implemented in practice. Further, the Executive Medical Director should ensure that this becomes a standard for the granting of obstetrical privileges within VIHA. VIHA RESPONSE & ACTIONS: The Child Youth Family Quality Committee (the VIHA committee that oversees quality for the perinatal program) has completed performance measures (indicators) for neonatology, with the remainder of the program to be completed by the end of 2012. Regular reporting and monitoring of these metrics is standard. Following a detailed analysis, it was determined that Operating Room staff would be performing the scrub nurse function. Hiring of five additional nurses is completed. The Department of Family Practice is currently reviewing its privileging requirements and processes. Fetal health surveillance training will be a requirement for physicians who provide obstetrical care. The Department of Midwifery will also ensure this standard is part of their privileging requirements. The auditing process is ongoing and a multi disciplinary workshop in Fetal Health Surveillance was completed May 2012.
Recommendation 11 Until a master plan of space requirements for a Maternal Fetal Health Centre are completed, VIHA should consider relocating its Biomedical Engineering from the 3 rd floor of VGH and use that space to provide immediate space requirements for the LDR. Recommendation 12 VIHA should post neonatal resuscitation algorithms and drug doses in easily found places wherever neonatal resuscitation might take place. This would be particularly relevant at this time for the main ORs. Recommendation 13 VIHA should encourage the SOGC to work with the Canadian Anesthesiologists Society to update and clarify their publication: Attendance at Labour and Delivery - Guidelines for Obstetrical Care (2000). In addition, VIHA may also wish to ask the Canadian Anesthesiologists Society to consider developing a formal process for such collaboration and review of potentially joint guidelines, as well as for the dissemination of these guidelines to its members. Both Societies could consider the development of such guidelines with the principles of Collaboration, Simplicity, (and) Transparency. Program leadership has been working with the space planning department to implement this recommendation and it will be considered further within the context of the findings of the Child Youth and Family VGH functional review. COMPLETED Algorithms are in place in areas where neonatal resuscitation occurs and a chart has been placed on the OR cart. A baby warmer was ordered and is now in place. Operating staff have been educated on calling a neonatal code and continuing education support from neonatology will take place. COMPLETED VIHA has linked with the Canadian Anesthesiologists Society and the Society of Obstetrics and Gynecology of Canada to request the updating of current guidelines and the development of joint guidelines. A response from the SOGC confirmed its intention to renew the 2000 standard, and a willingness to work with the CAS.
Respond when Outcomes, and the Design / Delivery of Care were not optimal Recommendation 14 Recognizing that VIHA has existing policies on disclosure and reporting, the Quality & Patient Safety portfolio, under the authority of the Chief Medical Officer and Chief Operating Officer, should develop an organizational policy and procedure for managing serious adverse events. The management plan should include the following aspects: 1) immediate management; 2) appropriate support for patients and for staff; 3) disclosure to the patient; 4) informing key stakeholders; 5) reporting; 6) analysis of an adverse event using an appropriate system based approach; 7) evaluation of individuals. Leadership Recommendation 15 VIHA and its Departments should come to a mutual agreement about working together in the future based on the principles highlighted below. Specifically - to protect the reputation of all involved and to (re)gain public confidence, VIHA and its medical staff should avoid using the media as a vehicle for airing differences, even if a patient suffers an unfortunate outcome. All methods for dispute resolution should be used when there are disagreements over the allocation of limited resources. Recommendation 16 VIHA should support formal leadership training and development amongst its medical staff and adequately resource its medical leaders so they function optimally in these extremely challenging but important roles. COMPLETED VIHA has a framework for disclosing and managing serious adverse events. This framework was reviewed to incorporate all areas recommended. VIHA will continue to expand our disclosure training program for staff and physicians. VIHA accepts this recommendation and is committed to working with departments and medical staff to improve teamwork, respect, communication and how disagreements are discussed. The principles behind this recommendation have been incorporated by the Perinatal Review Working Group, with an agreement in place among its members with respect to the ground rules. Additional work is planned as part of VIHA s Physician partnership strategy. VIHA agrees that leadership development is important and we have implemented a co-management leadership development program which is offered jointly to physician and administrative leads. Physician leaders also have the opportunity to access leadership training scholarships through the provincial Specialist
Services Committee and Shared Care Committee with VIHA endorsement. Principles Recommendation 17 Patient engagement VIHA should formally and consistently engage appropriate patients in all decisions made about improvements to maternalfetal care in Victoria. To facilitate, VIHA should consider creating a position to coordinate and lead patient engagement that is part of the Quality and Safety portfolio. Recommendation 18 Respectful, transparent relationships Safe care requires effective communication that only takes place consistently within relationships that are built on trust. Trust is gained through respect and transparency. VIHA, Department Heads and medical staff should model this principle in their relationships by committing to respectful communication and being as transparent as possible when negotiating physician payments. Recommendation 19 Recognizing that healthcare is a complex environment and healthcare providers should be supported within a just and trusting culture VIHA should examine the elements of a just and trusting culture and recognize that this is a foundation for a safety culture, and take steps towards implementing policies and procedures that would support and encourage such a culture. Recommendation 20 Responsibility and accountability A formal VIHA medical leadership series is being offered from February to November 2012 and a review of resources for medical leadership is ongoing. COMPLETED VIHA is committed to ensuring the patient voice is heard in decisions. VIHA has a dedicated staff position for patient engagement whose role is to develop and maintain a VIHA-wide patient engagement strategy. This strategy was reviewed to ensure the recommendation was met. VIHA also has a Patient Advisory Council to support patient engagement. We have facilitated their participation in a training program designed to increase the effectiveness of patients voices in decision making. COMPLETED/ONGOING VIHA s Executive remains committed to strengthening relationships and improving communications and we recognize that poor communication impacts the resolution of issues. Our co-management training program was reviewed to ensure it incorporates effective interpersonal communication and respectful, transparent relationships are an expectation of participants of the Perinatal Services Working Group. COMPLETED/ONGOING The foundation of VIHA s Quality System is based on the principles of forming a just and trusting culture. Adverse events reviews, whether system or patient focused, look at quality improvement rather than shaming or blaming individuals. Patient safety is a priority initiative in VIHA.
Successful improvement is only possible when clear accountability for implementation is specified. Therefore, for each recommendation VIHA accepts from these reports, responsibility should be assigned to a specific individual who is given an appropriate amount of authority to act. Recommendation 21 Continuous learning and improvement Since high quality and safe care require continuous improvement, VIHA should adopt and invest in a model for quality and safety management that provides: (1) appropriate methods for identifying improvement opportunities / hazards; (2) a method for prioritizing those opportunities; (3) a tool set of improvement methods; and (4) performance measures for the teams leading improvements. COMPLETED VIHA accepted all the recommendations in this review and has assigned clear responsibility for addressing each recommendation to a specific program and portfolio leader. Clear implementation timelines have been developed, recognizing that some recommendations will take longer to implement than others. Monitoring will occur through the VIHA Combined Quality Council (the committee which oversees quality and patient safety in VIHA). COMPLETED/ONGOING: VIHA has reviewed our existing model of continuous improvement and safety to identify opportunities for further improvement. The Patient Safety Learning System is the trigger for incident reporting, monitoring performance metrics and reviewing complaints. VIHA employs quality improvement consultants who work in the Quality, Research and Patient Safety portfolio. They have expertise in quality improvement tools and methodologies and work with programs to ensure use of tools, education and monitoring.