insights into implementing a patient safety bundle - npic · knowledge on the development and...

NPIC/QAS is a non-profit membership organization of perinatal centers across the United

States. Our Perinatal Center Data Base (PCDB) has collected over 12 million inpatient perinatal discharges since it was established in 1985. NPIC/QAS is dedicated to the improvement of perinatal health through comparative data analysis, health services

research, and professional continuing education.

If you would like more information on NPIC/QAS please email [email protected].

Continuing Education Webinar

Insights into Implementing a Patient Safety Bundle

mailto:[email protected]

Nurse Planner: Carolyn L. Wood, PhD, RN, Clinical Nurse Consultant Purpose/Goal(s) of this Education Activity: The purpose/goal(s) of this activity is to enable the learner to expand knowledge on the development and implementation of a patient safety bundle. 1.0 Contact Hour: This continuing nursing education activity was approved by the Northeast Multistate Division (NE-MSD), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. 1.0 AMA PRA Category 1 Credit™: Accreditation: Women & Infants Hospital is accredited by the Rhode Island Medical Society to sponsor intrastate continuing education for physicians. Women & Infants Hospital designates this online educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity has been approved for 1.0 Risk Management Credit.

This meeting has been approved for a total of 1.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.

Content Code: 1 - Clinical/Patient Safety

Education Type Code: 1 – Educational Program

American Society for Healthcare Risk Management (ASHRM)

Disclosures and Successful Completion of this Activity

No commercial support has been provided for this activity.

No one involved in planning or presenting this program has a conflict of interest.

There will be no discussion of off-label usage of any products.

In order to successfully complete this activity and receive 1.0 Contact Hour(s) or 1.0 AMA PRA Category 1 Credit™, you must attend/watch the webinar and return the completed post-test/evaluation to NPIC/QAS.

Implementing the Maternal

Patient Safety Bundles

Debra Bingham, DrPH, RN, FAAN

Consultant for the National Perinatal Information Center (NPIC)

Executive Director of the Institute for Perinatal Quality Improvement

Associate Professor, University of Maryland 1/13/2017 6

Objectives

• Describe why the national safety bundles were developed.

• Describe national perinatal quality and safety initiatives.

• Discuss examples of implementing elements of the national patient safety bundles.

[email protected] • ©Institute for Perinatal Quality Improvement

8

Eliminate preventable perinatal morbidity

and mortality and end disparities by working

with others

My Personal Mission

Over 350,000

Registered

Nurses care for

women and

newborns in the

United States. (Calculated from HRSA

2008 data)

[email protected] ©Institute for Perinatal Quality Improvement

Institute of Medicine - 2001

“It now takes an average of 17 years for

new knowledge generated by

randomized controlled trials to be

incorporated into practice, and even then

application is highly uneven.”


Institute of Medicine (2001). Crossing the quality chasm: A new health

system for the 21st Century, pg. 5.


http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html


“Simply totaling the raw, unadjusted data from all

states results in a reported U.S. maternal mortality

rate that more than doubled from

9.8 maternal deaths per 100,000 live births in 2000

to 21.5 in 2014.”

MacDorman, M.F., Declercq, E., Cabral, H., and Morton, C. (2016). Recent

increases in the U.S. maternal mortality rate. Obstetrics & Gynecology.


California Department of Public Health (2011). The California pregnancy associated

mortality review: Report from 2002 and 2003 Maternal Death Reviews. Pg. 27.

Need Both Clinical and Population Health Strategies

Lessons Learned from Reviews

Hemorrhagic death • 93% of all deaths were potentially preventable

• Lack of appropriate attention to clinical signs of hemorrhage

• Failure to restore blood volume, to act decisively with life

saving interventions

Severe Hypertension • 60% of maternal deaths were potentially preventable

• Failure to control blood pressure, to recognize HELLP

syndrome, to diagnosis and treat pulmonary edema

Pulmonary Embolism • “single cause of death most amenable to reduction by

systematic change in practice”

• Failure to use adequate prophylaxis

Berg CJ, et al. Obstet Gynecol 2005;106:1228-34; Cantwell R, et al. BJOG 2011

Mar;118 Suppl 1:1-203; Clark, SL. Semin Perinatol 2012;36(1):42-7

Mortality is the Tip of the Iceberg

1998-1999 compared to 2008-2009

• 75% increase in severe maternal complications during a hospital birth admission

• 183% increase in blood transfusions


Callaghan, W.M., Creanga, A.A., and Kuklina, E.V. (2012). Severe maternal

morbidity among delivery and postpartum hospitalizations in the United States.

Obstetrics & Gynecology.

RN Secondary Trauma Reported

• 35% of the 464 labor and delivery nurse members

of AWHONN who responded to a national survey

reported moderate to severe levels of secondary

traumatic stress

• Some reported that the stress was so severe they

were considering no longer being L&D nurses


Beck, C.T. and Gable, R.K. (2012). A mixed methods study of secondary traumatic

stress in labor and delivery nurses. Journal of Obstetric, Gynecologic & Neonatal

Nursing. Pp. 1-14

Describe national perinatal quality and safety initiatives.


HRSA -- Alliance on Innovation in Maternal Health (AIM)

Priorities for AIM are: • Reducing cesarean sections • 3 safety bundles

(Hemorrhage, VTE, HTN) • Preconception Care • Reducing Disparities


www.safehealthcareforeverywoman.org

Council on Patient Safety in Women’s Health Care

Dr. Bingham was the Vice Chair and Chair of the Council


Council on Patient Safety in Women’s

Health Care Safety Bundles

www.safehealthcareforeverywoman.org

http://www.safehealthcareforeverywoman.org/

http://www.safehealthcareforeverywoman.org/

National Partnership for Maternal Safety Bundles

“What every birthing facility in the U.S. should have…”

Maternal Patient Safety Bundles

• Maternal Mental Health: Depression and Anxiety

• Alliance on Maternal Health (AIM)

– Obstetric Hemorrhage

– Maternal Venous Thromboembolism

– Severe Hypertension in Pregnancy

– Safe Reduction of Primary Cesarean Birth

– Support after a Severe Maternal Event

– Reduction of Peripartum Racial/Ethnic Disparities

[email protected] • ©Institute for Perinatal Quality Improvement Co-Published in Journals for ACOG, ACNM, ASA, and AWHONN

May 2015

AAFP ACOG ACNM AWHONN SOAP +12 other professional orgs and other partners

Discuss examples of implementing elements of the national patient

safety bundles.

1/13/2017 [email protected]

©Institute for Perinatal Quality Improvement 24

Preparing to Lead • Choose a framework or model that works for you, the

innovation, and the context

– The constructs are similar with different names and different phases

– Seeing different frameworks helps you develop a better plan

• Learn from the other frameworks, models, & others

– Population

– Context

– Characteristics of the Innovation

25 [email protected] ©Institute for Perinatal Quality Improvement

There isn’t one best framework or model for all scenarios

Everett M. Rogers (More than 50 Years of Research)

• Diffusion of Innovations

– Knowledge

– Persuasion

– Decision

– Implementation

– Confirmation


Rogers, E.M. (2003). Diffusion of Innovations, 5th Edition. Free Press: New York.

Klein and Sorra (1996)


Weiner, B.J., Belden, C.M., Bergmire, D.M., and Johnston, M. (2011). The meaning

of measurement of implementation climate. Implementation Science, 6(78), pg. 4.

Quality Improvement Models

• Plan-Do-Study-Act

• MAP-IT – My favorite

– Mobilize

– Assess

– Plan

– Implement

– Track


Have a Plan – Be Systematic

Mobilize



Women die from postpartum

hemorrhage because they do not

receive early, effective and

aggressive lifesaving treatments.

California Department of Public Health (2011). The California pregnancy associated

mortality review: Report from 2002 and 2003 Maternal Death Reviews.

The California Maternal Quality Care

Collaborative (www.cmqcc.org)


Bingham, D., Lyndon, A., Lagrew, D., and Main, E. K. (2011). A state-wide obstetric

hemorrhage quality improvement initiative. American Journal of Maternal/Child

Nursing, 36(5), 297–304. doi:10.1097/NMC.0b013e318227c75f

Composite Case Example: 24yo G2 P1

at 38 wks gestation induced for “tired of being pregnant”

• After 8hr active phase and 2 hour 2nd stage, she gave birth,

NSVD, infant weighed 8lb 6oz

• After placental delivery she had an episode of atony that

firmed with massage. A second episode responded to IM

methergine and the physician went home (now 1am)

• The nurses called the physician 30 min later to report more

bleeding and further methergine was ordered

• 60min after the call, the physician performed a D&C with

minimal return of tissue. More methergine was given





Composite Case Example: 24yo G2 P1

at 38 wks gestation induced for “tired of being pregnant”, cont.

• 45 min later a second D&C was performed, again with minimal returns. EBL now >2,000

• Delays in blood transfusion because of inability to find proper tubing

• Anesthesia is delayed, but a second IV started for more crystaloid. VS now markedly abnormal, P=144, BP 80/30

• One further Methergine given and patient taken for a 3rd D&C; received 2u PRBCs

• After completion, she had a cardiac arrest from hypovolemia /hypoxia and was taken to the ICU when she succumbed 3 hours later





What are the Quality Improvement Opportunities Identified for

Reducing Mortality and Morbidity from OB Hemorrhage?


Mobilize - Change Champions

Explain WHY the change is needed

• A committed leader will not give up

• A confident change champion feels they are up to the task and will keep trying

• The patients we care for need committed and confident change champions who are willing to lead at all levels


Weiner, B.J. (2009). A theory of organizational readiness for change.

Implementation Science. Doi:10.1186/1748-5908-4-67

Find a few others who are willing to help!


“Never doubt that a small group of

thoughtful, committed citizens

(nurses) can change the world. Indeed, it is the only thing that

ever has.” Margaret Mead

US Anthropologist (1901-1970)

Assess Structure, Process, Outcomes, &

Balancing Measures


Broad Categories of Quality and Safety

• Underuse

• Misuse

• Overuse


Make Data Collection As Easy as Possible

• Use administrative data if possible

• Collect data that you can compare your outcomes with others

• Track trends in your data

Some examples of AIM reports from NPIC/QAS


www.NPIC.org


Be curious but not easily

distracted

Plan Be extremely specific on HOW to make the

needed changes!

Implement small tests of change.


Develop, Share, and Tweak your Implementation Plan

• Project Charter

– Time line

– Milestones

• Logic model

– Short-term and Long-term goals

• Driver Diagram


What one thing should I change? Keep focused! Be strategic!

Key Driver Diagram (or Logic Models) are Useful Tools


Implement


Persuasion

• Focus on the WHY before telling people WHAT, WHO, and HOW

• Let others help work out the HOW

• Plan vicarious experiences of self-discovery

• Try small tests of change


Simulation drill to show people how inaccurate estimating blood loss is

• Leaders

• Clinicians

• Characteristics of the QI Project

• Implementation Climate


Bingham, D. and Main, E.K. (2009). Effective implementation strategies and tactics

for leading change on maternity units. Journal of Perinatal and Neonatal Nurses.

24(1) pp.32-42.

Tailor Implementation

Strategies and Tactics Based

on the Barriers & Facilitators

Expected or Encountered

Major Strategies with Sample Tactics

• Education Strategy

– Grand Rounds, classes, simulation

• Discourse Strategy

– One-on-one discussions, reminders, rewards, disciplinary discussions

• Data Strategy

– Audit and feedback, public released data


Bingham, D. and Main, E.K. (2009). Effective implementation strategies and tactics

for leading change on maternity units. Journal of Perinatal and Neonatal Nurses.

24(1) pp.32-42.

WHAT behaviors need to change?

HOW will the changes be made?

What tools are needed?

Monitor the conversations.

The discourse either

enhances or detracts from the change efforts


Track


Track Progress • Structure

– Update policies and procedures

– Simulation drills

– Educate clinical team

• Process

– Quantification of Blood loss

– Risk Assessments

• Outcomes – with Balancing Measures

– ICU admission

– Blood transfusions


www.NPIC.org

Data are your friend & mirror


Start MAP-IT over!

Keep experimenting Don’t give up

1/13/2017 [email protected]

©Institute for Perinatal Quality Improvement 57

Quality

Improvement

should be like

climbing a

Spiral

Staircase


Sometimes QI is like my cat who chased

her tail, then caught her tail!


Now

what?

We can

get stuck

or go

around

in

circles!

Summary of Key Points


Key Questions • WHY is the change needed?

– “Burning Platform” – Institute for Healthcare Improvement

– Be specific (Who, Where)

• WHAT & WHO needs to change? – Structures, processes, and outcomes

• HOW will the change be made? – Be a Change Champion with Commitment & Self

Efficacy – Identify other early adopters – Provide tools to facilitate the change – Use data to objectively track progress

[email protected] ©Institute for Perinatal Quality Improvement

Keep trying

Celebrate

successes

Learn from

failures

Encourage

others

Tell your stories


Questions?

[email protected]

Questions & Comments

Participants are encouraged to ask questions and share comments.

• Please use the chat box for questions or comments.

• Questions and comments are visible only to presenters.

• Questions will be answered in the order in which they are submitted.

• Should there not be enough time to address your question(s), please email [email protected] so we may follow-up with you.

mailto:[email protected]

Thank You for Attending!

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