Protecting Mothers: Helping Hospitals Turn High Risk Into High Reward

In my white paper, Rethinking Patient Safety: Turning High Risk Into High Rewards, I outline what I’ve found to be the successful approach to increasing patient safety by reducing risk. It is a simple framework: Analyze. Assess. Educate. To bring it to life, I had a few respected healthcare voices share their stories.

While I purposely chose to share three very different scenarios to demonstrate how this applies in multiple settings, here I highlight my conversation with Julya Miner, Perinatal Safety Program Manager at St. Luke’s, during which we discuss how a service line setting – obstetrics – takes on a few key perinatal safety events to protect mothers and babies and gain traction for a broader risk mitigation effort down the road.

Framework to Increase Patient Safety by Reducing Risk:

Below is an excerpt of our conversation:

Wanting to dive deeper into how risk could be mitigated in one area of acute care, obstetrics (OB) was the logical choice. The stakes are high and the pressure is intense to keep moms and babies safe and healthy. I turned to St. Luke’s Health System in Boise, Idaho, a not-for-profit, integrated health system focused on local care from their eight hospitals and 200 outpatient centers and clinics. They have more than 2.5 million patient encounters per year and upwards of 7,500 births.

Recently, I talked with Julya Miner, Perinatal Safety Program Manager at St. Luke’s, about their very targeted approach to risk mitigation.

Q: You’ve been focused on reducing risk in OB for over a year now, working with our team here on very specific objectives. Can you outline what triggered these efforts?

A: The number of perinatal safety events was rising. Everything from OB hemorrhage to infant shoulder dystocia, maternal codes, emergent cesarean births and even maternal and neonatal ICU transfers. We were alarmed by the number of safety events and were committed to helping our care teams be better prepared to keep our patients safe. First, we explored the potential causative factors. Knowledge deficits, limited access to resources, team communication gaps, and missteps with fetal monitoring interpretation emerged as the most frequent opportunities. We decided to partner with Relias to help us tackle knowledge deficit. We wanted to know more about where the gaps in knowledge were before they surfaced in an event investigation. We wanted to be sure our teams were getting the education they needed to make things better.

Q: As organized and focused as your approach was, you still had to prioritize educational efforts and personnel. Talk a little about identifying the first areas to tackle.

A: It was important that we pinned our efforts to data so that we could measure outcomes over time. Plus, the numbers don’t lie. It was easier to get staff on board when they knew we had identified problem areas through data analysis and that we had solid benchmarks to measure progress. The data revealed four areas of focus: fetal assessment and monitoring, hypertensive disorders in pregnancy, obstetrical hemorrhage and shoulder dystocia. In February of 2017, we launched our educational efforts which included pathophysiology and treatment with critical thinking scenarios for each risk area.

Q: I know you had a very detailed implementation plan. Can you describe how that differed in approach for nurses and physicians?

A: We knew from the start that to get high participation rates we had to motivate team members in different ways. So, our implementation plan for nurses—who are employed by the health system and who expect and accept continuing education—was mandatory. For those nurses who had completed onboarding and had at least six months of OB experience, we set expectations for course completion from the outset. We also let them know that they’d be paid for the time they spent being assessed, learning, and reassessing. For physicians, we had to take a different approach. We invited them to participate and built in incentives—including making completion a quality metric that influenced bonuses. We encouraged peer-to-peer messaging and built ties to credentialing and American Board of Obstetrics and Gynecology (ABOG) maintenance of certification (MOC) credits.

Q: My understanding is that you started on OB hemorrhage first and just launched your fetal assessment and monitoring efforts at the end of last year with the hypertensive disorder module a few months ago. How’s it going?

A: We’re very pleased so far and have noticed that with each effort, enthusiasm and participation gains momentum. With the OB hemorrhage module, we exceeded our 60 percent completion goals for both providers and nurses in just seven weeks, boosted that to 81.5 percent in eight weeks and now are at 96 percent complete. Additionally, we have seen enthusiasm and interest from our colleagues in Anesthesia, ED and OR—all have requested to participate. Our Fetal Assessment and Monitoring module just launched last year and our completion rate is at 94 percent overall. Our latest initiative is on hypertensive disorders of pregnancy, and while it’s still early, I’ve been getting great feedback from staff. They claim this is the best one yet!

Q: Since the hemorrhage module has been in place for close to a year, can you share some of the impact it’s having on reducing risk?

A: We started by establishing our goal: to improve proficiency with prevention, recognition and management of OB hemorrhage. Then we set up measures for success, including improved scores on staff assessments and improved perinatal outcomes. Specifically, in outcomes we’re looking to eventually reduce the number of hemorrhage cases overall. But initially, our focus is on early recognition, effective management and reduction in the number of cases requiring massive transfusion, like those requiring transfusion of four or more units of packed red blood cells (PRBCs). We’re also measuring and looking for a decline in maternal and neonatal ICU transfers. To get all of that done we started with our staff assessments and then tailored our educational tactics to the identified needs of each participant. We didn’t want to waste anyone’s time going over material that they had already mastered.

“We started with our staff assessments and then tailored our educational tactics to the identified needs of each participant. We didn’t want to waste anyone’s time going over material that they had already mastered.”
– Julya Miner, Perinatal Safety Program Manager at St. Luke’s Health System

Our toolkit included just-in-time simulations, review of Relias Clinical Pearls (short bursts of learning that provide ongoing competency maintenance) in staff meetings and on skill days, visual cue cards, and more. Not only are we seeing positive patient outcomes in line with our stated goals—reducing massive blood transfusions and maternal and neonatal ICU admissions, we’ve also seen some welcomed savings in educational expenses. Focusing our educational interventions on the areas identified by data analysis allowed us to “right size” the education and eliminate unnecessary redundancy. We could target specific skills gaps, validate clinical competency, build clinician confidence and, within the first year, save about $74,000 in education costs.

Clearly, Julya Miner’s application of the “analyze, assess and educate” approach was successful in helping St. Luke’s reduce risk in OB. The stats alone speak for themselves, but when colleagues from other departments notice the success of this framework and request to participate, as Julya’s colleagues in Anesthesia, ED and OR did with the OB hemorrhage module, that is a true sign of success and can maximize the potential for reduced risk.

Conclusion

In my introduction, I mentioned that the analyze, assess and educate framework was a simple concept. So why doesn’t everyone just take that approach? Amongst all the companies that market risk-mitigation services and solutions, aren’t there options that follow this protocol? Unfortunately, not many.

A number of the health systems I’ve spoken with have fallen victim to data analysis promises. While the data may have successfully identified problems, it also left everyone wondering, “OK, what’s next? Where’s the solution?” And traditional learning systems present the opposite problem. Their one-size-fits-all educational approaches are unfocused, waste valuable time due to the lack of respect for existing provider skills and they don’t offer customized, ongoing educational support.

It comes down to this: To reduce the unintended variation that introduces risk— whether in the ED, the delivery room, or anywhere in the acute setting—it’s imperative to change the behavior of the whole team. Highly reliable organizations that continually improve patient safety, like St. Luke’s mentioned above, recognize the need for strong, motivated care teams and provide them with the framework for continuous improvement.

As we see in my conversation with Julya Miner, the synergy of using a platform like Relias, one which includes analytics, assessments and targeted learning, delivers results that are measurable and repeatable. We know that to change behavior, improve individual and team performance, and truly improve outcomes, you need to see beyond the issue and grab hold of the solution.

My final word—and this has informed my entire career as a physician—don’t focus on risk mitigation. Focus on patient safety and better outcomes. When you and your entire staff keep what’s best for the patient at the forefront, avoiding or minimizing risk becomes natural.

“… Don’t focus on risk mitigation. Focus on patient safety and better outcomes. When you and your staff keep what’s best for the patient at the forefront, avoiding or minimizing risk becomes natural.”
– Sandhya Gardner, M.D.

To learn how the Relias Platform can help you “analyze, assess and educate” your team members to increase patient safety by reducing risk, visit our Relias OB page.