Listening to our Patients B-3 10:45-12:00pm Sue Gullo, RN, BSN, MS Managing Director Institute for Healthcare Improvement (IHI)

OBJECTIVES Describe national surveys that provide information on what women want. Discuss the components of patient centered care. Identify 3 interventions that can be accomplished on your unit to support patient centered care. Assess your units culture and use quality improvement methodology to create a culture based on the patients needs. 2

Perinatal Oxytocin Bundles Perinatal Trigger Tool Common EFM Language and Training Reduce Variation- Meds, Emergencies Implement Techniques for Effective Communication Engage Patients and Families Establish a multi- disciplinary team training program Establish Huddles, Multi-disciplinary rounds Design Interventions From Trigger Tool findings Consistent (across disciplines) Credentialing Standards Collaborative And Supportive Culture Vacuum Bundle Effective Team with Active Sponsor Senior Admin and Board Level Support 3 months to 36 months Oxytocin Deep Dive- Pre-work 1-3 months 3-6 months 6-9 months 9-12 months months Patients on Improvement Teams Care is transparent Second Stage Safety

Perinatal Community Leadership help establish aims & goals Senior Executives support sponsor Assist in identification of needed resources and develops plan to provide Competent trained available staff Leadership and Sponsor Implement oxytocin and vacuum bundle Develop standard protocols for response to obstetrical emergency Design care process improvements based on trigger tool analysis, event detection, sentinel event Establish credentialing of core competency and training for all Use ACOG/AWHONN guidelines for documentation and staffing Standardize administration of high alert medications – oxytocin, magnesium sulfate, epidurals Reliable Design Reduce Variation Adopt common language and interpretation of EFM with multi- disciplinary training i.e NICHD criteria Implement techniques for effective communication i.e. SBAR Establish reliable techniques for handoffs Establish Team Response Protocols Establish a just culture – create consistent expectations for performance and behavior across all disciplines Implement Huddles Design Simulations Effective Teamwork Add patients and families on design teams, advisory groups Co-create and discuss a plan of care with the patient and family Conduct Patient/Family Focus Groups Engage patients & families as partners in care Communicate openly and honestly with family and patients at regular intervals Do what you say, mean what you do Include patients and families on improvement teams Patient/Family Centered Care Reduce harm to 5 or less per 100 live births Zero incidence of elective deliveries prior to 39 weeks Augmentation Bundle(s) Composite or Compliance great than 90% Improve organizational culture of safety survey scores in Perinatal units by 25% 100% of participating teams will have documentation of Patient & Family Centered Care

Nothing about me, without me. 5

Core Concepts of PCC 6

Respect and dignity Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care. 7

Information Sharing Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making 8

Participation Patients and families are encouraged and supported in participating in care and decision-making at the level they choose. 9

Collaboration Patients and families are also included on an institution-wide basis. Health care leaders collaborate with patients and families in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care. 10

2 Key Documents Evidence Based Maternity Care: What It Is and What It Can Achieve maternity-care.pdf Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives 11

Stakeholders Policymakers Healthcare professionals Childbearing women 12

The First Law of Improvement Every system is perfectly designed to achieve exactly the results it gets. Paul Batalden

2002 The landmark Listening to Mothers I survey (2002) was the first time that women in the United States were surveyed at the national level about their maternity experiences. 14

Underuse 2006 Cost of Interventions- Misuse, Overuse, Underuse Only a small proportion of women experienced these beneficial practices: use of highly rated drug-free methods of pain relief (e.g., immersion in a tub, shower, use of large "birth ball"), monitoring the baby with handheld devices instead of electronic fetal monitoring, drinking fluids or eating during labor, moving about during labor, giving birth in non-supine positions, and pushing guided only by their own reflexes rather than caregiver-directed pushing. 15

Childbirth is the #1 reason for hospital admission Cesarean birth is the #1 surgical procedure in the United States.

Click to edit Master title style Click to edit Master subtitle style 17 Change in Distribution of Births by Gestational Age: United States, Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics Source: CDC/NCHS, National Vital Statistics Systems.

Click to edit Master title style Click to edit Master subtitle style 18 U.S. Cesarean Section and Labor Induction Rates Among Singleton Live Births by Week of Gestation, 1992 and Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April Induction 2002 C-S 1992 C-S 1992 Induction Early Term

Click to edit Master title style Click to edit Master subtitle style 19 Rates of Induction of Labor by Race and Hispanic Origin in the U.S. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics

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Key Theme An integrated system is key to achieving the aim of an excellent patient and family experience of inpatient hospital care. For example, excellent partnerships with patients contribute to safer care, and safer care results in better patient experiences.

Key Theme Leadership behavior at the executive, middle, and front-line levels is essential to achieving exceptional results. Leadership commitment to creating an environment that nurtures and continuously improves the patient and family experience and results in positive outcomes is essential.

Key Theme The path to achieving excellence in the patient and family experience includes a group of dynamic, positively reinforcing actions rather than a linear set of activities. For instance, effective leadership engages the hearts and minds of staff and providers, which in turn provides a foundation for respectful team communication and partnerships with patients and families, which in turn reinforces staff and provider engagement.

Safety Culture Refers to the extent to which individuals and groups will: Commit to personal responsibility for safety Act to preserve, enhance and communicate safety concerns Strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes or near misses Be rewarded in a manner consistent with these values

Listening Involves effective communication 32

We are competent. We have teamwork and communication failures.

Patient care requires groups to work together effectively NASA research found more than 2/3 of air crashes involve human error – especially failures in teamwork Professional training focuses on technical, not interpersonal skills Teamwork

Perceptions of Teamwork in L&D Journal of Perinatalogy, June 2006 Only 55% of respondents found it easy to speak up if they perceived a problem with patient care, and only half felt that conflicts were appropriately resolved. In medicine, questions seeking advise or knowledge are welcome, whereas questioning someones performance or disagreeing with their actions is taboo.

Communication breakdowns Resentment or indifference to team concept Competing priorities and goals among team members Language problems Failure to compromise with goals Poor coordination of activities among team members Role confusion – Role conflict Negative Team Factors

What Impacts Our Performance? Fatigue Lack of sleep Illness Drugs or alcohol Boredom Frustration Fear Stress Shift work Reliance on memory Reliance on vigilance Distractions Noise Heat Clutter Motion Lighting Too many handoffs Unnatural workflow Procedures or devices designed in an accident prone fashion

Provider Perspective In medicine, it is a challenge to be the one to criticize or evaluate a colleague when you perceive that mistakes are being made, or when you disagree with management.

Sharp End

Case Study: A 38-Year-Old- Woman With Fetal Loss and Hysterectomy JAMA, August 17, Vol 294, No 7 Benjamin P. Sachs, MB, BS, Discussant

Background 38 year old woman admitted to the hospital for elective delivery of her first child, but the admission ended tragically with fetal loss, hysterectomy, and a prolonged hospitalization.

Dr. Sachs Although the complication that occurred is rare, unfortunately the types of failures in communication and teamwork are not.

6 System Failures Identified 1.Communication was poor 2.Mutual performance cross monitoring 3.Inadequate conflict resolution 4.Poor situational awareness 5.Physician workload was too high and there was no contingency plan in place to deal with the overload 6.Physician on call displayed vigilance fatigue

Lessons Learned Patients and Family: Appropriate consent Communication Feeling safe Able to ask for additional help Code H

A Reason to Change Luke Vincent Powers September 11, 2009 Presented by: William Powers

Discussion 1.What do you do well, and why? 2.What can you do better, and why? 3.What would you do differently, and why?

What would you like to improve? Why? How do you know? What are your current results? How will you know a change is an improvement? 47

What can every one of you do tomorrow? 1.No longer accept the status quo- ask why? 2.Start with one patient, one nurse, one doctor. 3.Stop the line when it is not right. 4.Love what you do.

What are we trying to Accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? The Model for Improvement ActPlan StudyDo Source: Langley, et al. The Improvement Guide, strategy The three questions provide the strategy tactical The PDSA cycle provides the tactical approach to work

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