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1. General Information 1. General Information Application for Vanguard Award from: Dignity Health 185 Berry Street, Suite 300 San Francisco, CA 94107 Contact Person: Suzanne Wiesner, RN, MBA/HCM, C-EFM Director, Maternal Child Health Services [email protected] 916-851-2789 Kathryn Tipton Executive Coordinator [email protected] 916- 851-2902 Title: Perinatal Safety Initiatives Favorably Impacts 60,000 Deliveries Identified Topical Areas for focus: Patient Safety Performance Improvement Brief statement by an executive leader in support of the application: On behalf of Dignity Health and senior leadership, we are most supportive of the submission of this application for three reasons. First, through the dedication of many committed individuals, from nursing and physician leaders to the 1,600 nurses and 600 obstetricians, the adopted initiatives and programs consistently decrease patient harm and patient outcomes. We honor the work of the healthcare providers to better serve our patients. Secondly, we strive for transparency and sharing of all materials externally so that others might benefit and improve their patient outcomes. We believe that the practices and results apply at large multi-hospital systems as well at a single hospital. Finally, the results of the Perinatal Safety Program support the belief that if you decrease harm to patients, costs will also decrease. At Dignity Health, there are 60,000 deliveries annually and adoption of evidence based practices results in less harm and more favorable outcomes. There has been corresponding savings in hospital professional liability costs. Knowing we have a culture that promotes safe practices allows nurses and physicians to continue to support “first no harm.” We proudly support the submission of this application. 1 Sincerely, Barbara Pelletreau, RN, MPH Senior Vice President, Patient Safety [email protected] 415-438-5567 2. Executive Summary, which must contain a summary of results. Dignity Health has committed to improving perinatal patient results and experiences across all hospitals. Through the adoption of evidence based practices and the clear measurements for tracking process and patient outcomes, Dignity Health has consistently reported significant improvement in multiple metrics. Collaborating with physicians, nurses and other experts allows minimal resources to achieve great gains. Maximizing technology to assist care providers in doing what is right and then being able to extract results “real time” allows hospitals to identify “fall outs” make improvements. The over results are powerful. There has been a reduction in brachial plexus injuries by 28%, shoulder dystocia by 19%, eclampsia by 46% and cesarean section rate by 12%. There has been considerable focus also on the patient and employee experience (which is not highlighted in this application), and this has complimented the patient outcome results. In addition to patient outcomes, there has been steady improvement in the Culture of Safety Survey results with a steady 5% increase. 3. Background and relevance of the problem being addressed and effort undertaken. Dignity Health has 37 hospitals with 29 hospitals offering perinatal services, accounting for approximately 60,000 deliveries annually. With national rates of maternal morbidity and mortality on the rise, health care providers and leaders must take action. Standardization of care and implementation of evidence-based practices can have a significant impact on outcomes, particularly where there is an opportunity for early recognition and intervention. As one of the largest health systems in the nation, Dignity Health’s commitment to improving maternal and neonatal outcomes will continue to have a significant impact. 4. Description of the effort, including the scope, processes, strategies and tactics utilized, challenges encountered and how they were addressed. Efforts to improve quality and safety within Perinatal Services include collaboration among system and facility-level leaders. These partnerships have been critical in driving the change necessary to improve outcomes. Some of the tactics utilized: 2 Standardization – system wide efforts to standardize policies and support evidence- based care through the use of care bundles: Obstetrical Hemorrhage, Oxytocin Management, Prevention of Hyperbilirubinemia, Operative Vaginal Delivery, Shoulder Dystocia and Hypertension in Pregnancy/Preeclampsia Management Accountability – full compliance with standardized policies is measured and reported (the motto is every patient, every time) Transparency in a Learning Organization – monthly Shared Learnings call, sharing of “closed” claims during our in-person meetings, outcomes/metrics by facility as published in a monthly scorecard by hospital for all to review Physician Collaboration – system and facility level expertise and engagement Standardized Education – through online modules and reinforced learning through simulation/drills (includes accountability for completion) Perinatal Safety Specialist Role – improves frontline engagement in safety efforts Perinatal Claims Specialist - collaboration from claims management (hospital professional liability) with Perinatal Safety with a focus on prevention and learnings along with standard of safe care Enhanced Partnerships – system and facility leads work together to improve quality/safety (Annual Perinatal Safety Summit, Regional In-Person Meetings, ongoing support, etc.) 5. Description of the results of the effort. Through the adoption of best practices, the following results have been reported: Reduction of eclampsia by 46%, low risk cesarean delivery rate by 12%, brachial plexus injury rate by 29%, shoulder dystocia by 19% System wide compliance with hyperbilirubinemia, oxytocin management, shoulder dystocia, operative vaginal deliveries, obstetrical hemorrhage and preeclampsia management bundles range from 84% to 97% Reduction of average cost of delivery for hospital professional liability decreased significantly (from $110 to $29 per delivery over six years) 98% obstetrical nurses and 43% obstetricians have completed on-line modules for proficiency, including knowledge and judgment. Results for the Shoulder Dystocia module show 24 of 29 (83%) Dignity Health facilities at or above the 75th percentile. Facilities above the 50th percentile include: Fetal Assessment and Monitoring 22/29 (76%), Obstetrical Hemorrhage 23/29 (79%), Shoulder Dystocia 28/29 (97%) and Hypertension in Pregnancy 17/29 (59%). 6. Discussion of the significance of the results. How do the results demonstrate outstanding achievement? Dignity Health’s impact on the state of maternal health is significant. Improving the lives of families through reducing birth injuries, maternal and neonatal complications of pregnancy and 3 reducing harm, is significant for every family served. The efforts demonstrate that through partnerships with leaders, providers and staff, Dignity Health can be an example for others. The variation among our facilities, in delivery volume, urban vs rural, employed vs non- employed providers, etc., is also an example of success. 7. Description of sustainability and scaling of the achievements. The results are sustained through the monthly “Perinatal Scorecard” showing results of over thirty measures for each hospital and as a system. The thirty measures are divided into key “buckets” – safety, patient experience, public reporting, culture of safety and competencies. In addition, hospital professional liability results are shared quarterly with leadership showing the cost of claims and frequency of lawsuits. Adoption of best practices and “hardwiring” best practices resulted in no medical malpractice claims from shoulder dystocia, OB hemorrhage, and hyperbilirubinemia. Collectively policies and practices are designed by multi-disciplinary work groups, approved and adopted by all. A one hour monthly call with nursing and physician leaders provides a steady platform to introduce new initiatives, share results and address questions. In addition to the above, there has been an annual “Perinatal Summit” complimented by regional in person meetings. These multidimensional approaches support adoption, alignment and sustainability. 8. Description of key lessons learned and any advice to colleagues who might try to undertake a similar effort. Here are the key lessons learned: Identify evidence based practices to improve patient care and outcomes Measure effectiveness of adoption of evidence based practices with nurses, physicians and leadership Track results by hospital and then by physician for identification of fallouts and improvement opportunities Incorporate specific stories from root cause analysis for general across the board learnings Identify physician champions to align local physicians Focus on low performing hospitals to address local challenges/obstacles Make it easy to do what is right for frontline care givers by providing “toolkits” with all the necessary information and align electronic health records Focus on what is right, not who is right 4 5 Attachments Evidence-Based Practice Bundles Hyperbilirubinemia Oxytocin Management Operative Vaginal Delivery Risk factors identified and Pre-Use Checklist completed Elective Operative Vaginal Delivery documented In-Use Checklist completed every Pre-Assessment completed Documentation of written parent 30 minutes while oxytocin is Documentation of informed education and verbal instructions infusing during labor consent
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