ANN HENDRICH, RN, PHD, F.A.A.N. SENIOR VICE PRESIDENT, CLINICAL QUALITY & SAFETY

CNO & EXECUTIVE DIRECTOR, PATIENT SAFETY ORGANIZATION

SEPTEMBER 10, 2012

Lessons From Obstetric and Prenatal Safety Intervention

Program (OPSIP)

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Introduction

Ascension Health, the nation’s largest Catholic and nonprofit healthcare system, aims to demonstrate that implementing principles of High Reliability in five test sites across Ascension Health will lead to significantly improved patient safety and reduced medical liability in the high-risk practice of obstetrics.

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Hypotheses

1. Decrease in shoulder dystocia injury rates and infant harm when the “shoulder bundle” is introduced

2. Change in delays of treatment when fetal distress occurs and an increase in cesarean section effectiveness (necessity and timeliness) when the protocol guidelines are followed

3. Reduction in the frequency and severity (settlement amount) of claims when full disclosure is implemented

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Hypotheses continued

4. Increase in reporting of Serious Safety Events when five elements of High Reliability have been adopted

a) Preoccupation with Failureb) Reluctance to Simplifyc) Sensitivity to Operationsd) Commitment to Resiliencee) Deference to Expertise

5. Decrease in all birth trauma events and rates

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Study Design

To demonstrate that implementing principles

of High Reliability will lead to significantly

improved patient safety and reduced medical

liability in the high-risk practice of obstetrics.

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Project Aims

1. Establish an evidence-based obstetrics practice model to improve patient safety.

2. Implement a quick-response liability model. 3. Develop a standard process for data

collection, storage and analysis.

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Labor & Delivery Units at Five Hospitals

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Data Collection

• >400 variables on mothers and infants• Training tracked with ‘dose intensity’ charts

reflecting percentage of OB doctors and nurses trained

• Reporting of OB-related Serious Safety Events in SafERSystemTM

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Major Milestones

• 593 nurses/physicians trained in Year 1 on multiple interventions

• 425 nurses/physicians trained in Year 2 on multiple interventions

• 12,200 mothers enrolled in the study from 1/1/2011 – 6/30/2012

• 85% average consent enrollment rate at five sites

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Interventions1. Electronic Fetal Monitoring e-learning module

– 277 physicians & 390 nurses trained

2. Shoulder dystocia bundle and training Shoulder dystocia bundle tool developed – 281 physicians & 383 nurses trained

3. TeamSTEPPS® and simulation training with hi-fidelity Noelle mannequins– 409 physicians & 653 nurses trained

4. Disclosure communication and cause analysis training– 407 clinicians trained on disclosure & 76 trained on cause

analysis

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OBERT responds to unexpected adverse events within 24 hours• Determines if care was reasonable or not• Shares (discloses) findings with patient/family

Obstetric Event Response Team (OBERT)

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Obstetric Event Response Team (OBERT)

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• 497 events reviewed by OBERT• 246 documented coordinated communications

(disclosures)– 1 initiated by family– 1 with no documentation– 244 initiated by clinicians

• Early results suggest fewer claims– Notice of Intent/claim for event occurring after April 1, 2011– Notice of Intent/claim for an event that occurred in October

2010 (prior to training)

Results from April 1, 2011 – June 30, 2012

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• Ethnographer studying impact of coordinated communication on providers and patients/families

• One medical liability carrier offers substantial premium discount to physicians who complete all mandatory training

Results from April 1, 2011 – June 30, 2012