Implementing a variety of evidence-based clinical and non-clinical interventions, such as open and transparent “full disclosure” communications, at five hospital locations significantly reduced infant harm, resulting in improved care of mothers and babies for Ascension Health.
Ascension Health’s Excellence in Obstetrics demonstration site study was made possible in part by a $2.9 million grant from the Agency for Healthcare Research and Quality (AHRQ), as part of its Patient Safety and Medical Liability Initiative. The Excellence in Obstetrics demonstration project began in January 2011 and concluded on June 30, 2013.
The first article from the study about its full disclosure protocol, titled “Ascension Health’s Demonstration Of Full Disclosure Protocol For Unexpected Events During Labor And Delivery Shows Promise,” appears in the January 2014 edition of the journal Health Affairs.
Five Ascension Health hospitals participated in the demonstration site study:
- St. Vincent’s Birmingham in Birmingham, Ala
- St. John Hospital and Medical Center in Detroit, Mich
- Columbia St. Mary’s in Milwaukee, Wis
- Saint Agnes Hospital in Baltimore, Mar
- Sacred Heart Hospital on the Emerald Coast in Miramar Beach, Fla
More than 20,000 mothers and their infants participated across the five demonstration sites, representing one of the largest consented studies for mothers nationally.
“We care passionately about the safety of our mothers and babies,” said Ann Hendrich, RN, PhD, Ascension Health’s Senior Vice President, Chief Quality/Safety and Nursing Officer, Principal Investigator for the demonstration program and one of the co-authors of the Health Affairs piece. “The goals of the study included establishing a uniform, evidence-based obstetrics practice model based on the idea that eliminating unnecessary variability in obstetrics practice, strengthening the physician-nurse teaming, would translate into improved patient safety and patient experience; and when things don’t go as expected, communicating openly with a quick response that included standardized practices for identifying, reporting, responding to, investigating and disclosing medical errors and adverse outcomes.”
Interventions focused on two primary areas: injurious deliveries (including the best practice use of electronic fetal monitors, and minimizing infant injury during difficult shoulder dystocia deliveries) and communication with the patient and her loved ones when an unexpected event occurred.
“Ascension Health implemented a care team model at each demonstration hospital,” Ann said. “The local care team was called the Practice Engagement Team, or PET. Each PET included an Obstetric Physician Leader and a project manager. Other PET members included an OB nurse leader and Risk Manager from each demonstration site, as well as a medical records coder to ensure accurate coding and documentation of adverse events. The PETs were fundamental in ensuring that each educational element was implemented for all physicians and nurses and that any potential or actual obstetric adverse event was reviewed with appropriate action initiated within 24 hours.”
Demonstration site results validated the study hypotheses. Results included:
- A completion rate of 90 percent for all physicians and nurses on all education and training elements: Electronic Fetal Monitoring (EFM) and shoulder dystocia e-learning, simulation and TeamSTEPPS™ training, disclosure and root cause analysis training, and implementation of a new Ascension Health shoulder dystocia bundle.
- A 64 percent reduction in the rate of actual and potential liability cases involving shoulder dystocia, from 4.19 per 1,000 births during the pre-grant period to 1.50 per 1,000 births at the demonstration sites. (The non-demonstration site reduction was 46 percent, from 1.57 to 0.85.)
Based on the success of the Excellence in Obstetrics demonstration project, Ascension Health has begun to spread the care model as a standard for all obstetrics units throughout the health system. A System-wide conference for obstetrics leaders was held in December 2013 to launch the effort.
Another article in the January 2014 edition of Health Affairs, “How Policy Makers Can Smooth The Way For Communication-And-Resolution Program,” is co-authored by one of Ascension Health’s Risk Management leaders. A third article , The Moral Imperative To Disclose Medical Error: Doing The Right Thing,” co-written by several leaders from Ascension Health including President and Chief Executive Officer Robert Henkel, appears on the Health Affairs blog.
