insights into implementing a patient safety bundle - npic · knowledge on the development and...
TRANSCRIPT
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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
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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.
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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)
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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.
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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
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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
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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
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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.”
[email protected] • ©Institute for Perinatal Quality Improvement
Institute of Medicine (2001). Crossing the quality chasm: A new health
system for the 21st Century, pg. 5.
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[email protected] • ©Institute for Perinatal Quality Improvement
http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
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[email protected] • ©Institute for Perinatal Quality Improvement
“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.
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[email protected] • ©Institute for Perinatal Quality Improvement
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
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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
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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
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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.
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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
[email protected] • ©Institute for Perinatal Quality Improvement
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
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Describe national perinatal quality and safety initiatives.
[email protected] • ©Institute for Perinatal Quality Improvement
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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
[email protected] • ©Institute for Perinatal Quality Improvement
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www.safehealthcareforeverywoman.org
Council on Patient Safety in Women’s Health Care
Dr. Bingham was the Vice Chair and Chair of the Council
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[email protected] • ©Institute for Perinatal Quality Improvement
Council on Patient Safety in Women’s
Health Care Safety Bundles
www.safehealthcareforeverywoman.org
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National Partnership for Maternal Safety Bundles
“What every birthing facility in the U.S. should have…”
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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
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[email protected] • ©Institute for Perinatal Quality Improvement Co-Published in Journals for ACOG, ACNM, ASA, and AWHONN
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May 2015
AAFP ACOG ACNM AWHONN SOAP +12 other professional orgs and other partners
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Discuss examples of implementing elements of the national patient
safety bundles.
1/13/2017 [email protected]
©Institute for Perinatal Quality Improvement 24
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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
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Everett M. Rogers (More than 50 Years of Research)
• Diffusion of Innovations
– Knowledge
– Persuasion
– Decision
– Implementation
– Confirmation
[email protected] • ©Institute for Perinatal Quality Improvement
Rogers, E.M. (2003). Diffusion of Innovations, 5th Edition. Free Press: New York.
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Klein and Sorra (1996)
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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.
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Quality Improvement Models
• Plan-Do-Study-Act
• MAP-IT – My favorite
– Mobilize
– Assess
– Plan
– Implement
– Track
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Have a Plan – Be Systematic
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[email protected] • ©Institute for Perinatal Quality Improvement
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.
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The California Maternal Quality Care
Collaborative (www.cmqcc.org)
[email protected] • ©Institute for Perinatal Quality Improvement
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
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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
[email protected] • ©Institute for Perinatal Quality Improvement
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
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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
[email protected] • ©Institute for Perinatal Quality Improvement
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
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What are the Quality Improvement Opportunities Identified for
Reducing Mortality and Morbidity from OB Hemorrhage?
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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
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Weiner, B.J. (2009). A theory of organizational readiness for change.
Implementation Science. Doi:10.1186/1748-5908-4-67
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Find a few others who are willing to help!
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“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)
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Assess Structure, Process, Outcomes, &
Balancing Measures
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Broad Categories of Quality and Safety
• Underuse
• Misuse
• Overuse
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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
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www.NPIC.org
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www.NPIC.org
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Be curious but not easily
distracted
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Plan Be extremely specific on HOW to make the
needed changes!
Implement small tests of change.
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Develop, Share, and Tweak your Implementation Plan
• Project Charter
– Time line
– Milestones
• Logic model
– Short-term and Long-term goals
• Driver Diagram
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What one thing should I change? Keep focused! Be strategic!
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Key Driver Diagram (or Logic Models) are Useful Tools
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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
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Simulation drill to show people how inaccurate estimating blood loss is
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• Leaders
• Clinicians
• Characteristics of the QI Project
• Implementation Climate
[email protected] • ©Institute for Perinatal Quality Improvement
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
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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
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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.
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WHAT behaviors need to change?
HOW will the changes be made?
What tools are needed?
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Monitor the conversations.
The discourse either
enhances or detracts from the change efforts
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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
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www.NPIC.org
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Start MAP-IT over!
Keep experimenting Don’t give up
1/13/2017 [email protected]
©Institute for Perinatal Quality Improvement 57
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Quality
Improvement
should be like
climbing a
Spiral
Staircase
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Sometimes QI is like my cat who chased
her tail, then caught her tail!
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Now
what?
We can
get stuck
or go
around
in
circles!
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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
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Keep trying
Celebrate
successes
Learn from
failures
Encourage
others
Tell your stories
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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.
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Thank You for Attending!
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