forming and sustaining a large quality improvement collaborative: northwest obstetric patient safety...
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Forming And Sustaining A Large Quality Improvement Collaborative:
Northwest Obstetric Patient Safety Collaborative
The Quality Colloquium
August 2008
Presented byMarion Constable CNM, MSN
Kristine Larison RN, MBA-HCA
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Objectives
Crisis leads to opportunity
Collaborative Formation
Work of the Collaborative
Accomplishments/results
Crisis and Opportunity
3
4
Oregon Malpractice Crisis
1999 The Oregon Supreme Court struck down the cap on non-economic damages as unconstitutional.
Loss of OB providers in critical access areas
In 2002 the board of NPIC determined that OB claims frequency and severity warranted serious analysis in order to mitigate risk exposure.
Oregon Rates 1983-2008
Northwest Physicians InsuranceOregon Rates by Year for OBG (Class 7/6), 1M/3M limits
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
Demand – OBG vs All Other
0
1000000
2000000
3000000
4000000
5000000
6000000
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
OBGYN ALL OTHERS
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Retrospective & Actuarial to Prospective & Clinical
Traditional Approach Professional Liability : Retrospective review of claims: Actuarial perspective (frequency, severity by specialty class, premium)
Change in thinking: Clinical Review Review of all OB claims, whether dismissed, settled or went to
trial from the inception of the company through the year 2001 (22 years).
Determine what where the professional liability risks in Obstetrics.
Claims Analysis Findings
Identified areas of risk:
Fetal monitoring: pattern recognition & documentation
VBAC: lack of ability to respond and resource uterine rupture
Injuries associated with operative vaginal delivery
Shoulder Dystocia-management of OB emergency
Cesarean Delivery-decision to incision delays
Teamwork (lack of)
Communication (ineffective, ambiguous, absent)
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2003 Mandate
Once the NPIC task force identified these risk areas they put together a full day OB Symposium in 2003 to address them. “Current Issues in Patient Safety, Practice Performance and Professional Liability Protection”
Attendance Mandated: All “insured's” as a condition for future insurability.
Physicians asked to invite Perinatal nursing leaders, hospital risk managers and nurse educators.
Collaborative Formation
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Shift to Collaborative Learning
Didactic education programs for the individual practitioner were not producing learner satisfaction or desired results.
Research ways to more effectively learn and produce change in cross disciplinary teams.
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Why a Collaborative?
Collaborative Benefits: Intense effort to share knowledge and improve Perinatal patient safety.
Networking
– Frequent communication
– Best practices, access to experts
Cooperation
– Leap Frog
– Share experience, shared information, shared ideas
Coordination
– Intensity
– Repetition
– Support structure-coaches-documented progress-
– Collaborative work products
13
Original Collaborative Structure
Northwest Physicians Insurance Company OB Collaborative (NPIC)
VP Patient SafetyD.Zimmer
Program DirectorM. Constable
Chairman OB Task ForceL. Marzano
Participating Hospitals Oregon/Idaho
Adventist Medical Center-Asante Rogue Valley Medical Center -Asante Three Rivers Medical Center-Holy Rosary Hospital-Kaiser Sunnyside Medical Center-Legacy Health System-Legacy Emmanuel-McKenzie Willamette Mercy Medical Center-Oregon Health &Science U.( OHSU)-Peace Health Corporation-Peace Health Sacred Heart-Peace Health Harbor Hospital-Providence Health System-Providence St. Vincent-Salem Hospital -Samaritan Albany General-Willamette Falls Hospital -Willamette Valley Medical. Center-Kootenai Medical Center- 17 hospitals
Experts: Consumers Advancing Patient Safety( CAPS) ,Parents of Infants & children w/ Kernicterus( PICK)
Hospital Corp. of America (HCA)-Kaiser Permanente: Perinatal Patient Safety Project,Partnership for Patient Safety -Physician Insurers Association of America (PIAA)
OB Emergency Team Response
EFM CommonNomenclature
Communication SBAR+R
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Current Collaborative Structure
Northwest Physicians Insurance Company OB Collaborative (NPIC)
VP Patient SafetyD.Zimmer
Program DirectorM. Constable
Chairman OB Task ForceL. Marzano
Participating Hospitals Oregon/Idaho
Experts: Consumers Advancing Patient Safety( CAPS) ,Parents of Infants & children w/ Kernicterus( PICK)
Hospital Corp. of America (HCA)-Kaiser Permanente: Perinatal Patient Safety Project,Partnership for Patient Safety -Physician Insurers Association of America (PIAA)
OB Emergency Team
Response Workgroup
Simulation BasedTraining
Workgroup
25 Hospitals 3 Health Systems
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Collaborative Structure
Work GroupCoach/Facilitator
Content Experts
Monthly Conference
Call
Collaborative Member Hospital Teams
Annual Patient Safety Symposium
Quarterly Topic of interest
Webinar
Collaborative Learning
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EFM Common Nomenclature-2006 Established need for standardized language in the interpretation,
description & discussion of EFM tracings. NICHD selected, ACOG endorsed
Researched options for training
Advanced Practice Strategies Advanced Electronic Fetal Monitoring e-learning courseware reviewed & offered to collaborative members.
2,500+ seats purchased
Single contract avoid legal fees
>40% volume discount
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Perinatal Bundle-2008
Second collaborative initiative Perinatal e-learning bundle
Shoulder Dystocia
Operative Vaginal Delivery
Structured Communication
2,800+ seats purchased
38% volume discount
Communication Workgroup
The group developed a “SBAR+R Toolkit” Consisting of 26 educational aids designed to facilitate the implementation.
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OB Emergencies Team Response
Evaluate perceptions about the value of team training to improve preparedness for OB emergencies.
Anonymous survey administered to all staff who respond to obstetric emergencies in 7 Oregon Collaborative hospitals from June 2006-August 2006.
614 (74.5%) staff responded
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Teamwork
90% felt confident the appropriate staff would respond to an OB emergency.
50-70% reported that other staff were confused about their role in an OB emergency.
84% were confident that emergency drills or simulation-based team training would improve team performance.
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TeamworkFigure 2. Rating of Teamwork Effectiveness(1=least effective versus 10=most effective)
7.3
7.7
8.1
6
6.5
7
7.5
8
8.5
9
Deliveries/Year
< 100 100-399 > 400
P for trend < 0.0001T
eam
Eff
ecti
vene
ss S
core
*
* Adjusted for team, delivery and OB emergency experience, training to work as a team,
length of training and working in same institute
By Hospital Delivery Volume
STORC Safety Initiative: A Multicenter Survey on Preparedness & Confidence in Obstetric EmergenciesJeanne-Marie GUISE, MD, MPH123, Sally Y. SEGEL, MD1, Kristine LARISON RN4, Sarah M. JUMP MD, MPH1, Marion CONSTABLE, RN, MSN,
CNM4, Hong LI MD2, Patricia OSTERWEIL BS1, Dieter ZIMMER FAAMA4
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TeamworkFigure 2. Rating of Teamwork Effectiveness(1=least effective versus 10=most effective)
STORC Safety Initiative: A Multicenter Survey on Preparedness & Confidence in Obstetric EmergenciesJeanne-Marie GUISE, MD, MPH123, Sally Y. SEGEL, MD1, Kristine LARISON RN4, Sarah M. JUMP MD, MPH1, Marion CONSTABLE, RN, MSN,
CNM4, Hong LI MD2, Patricia OSTERWEIL BS1, Dieter ZIMMER FAAMA4
7.67.9
6.6
8.2 8.3
5
6
7
8
9
10
OB
Tea
m E
ffec
tive
ness
Sco
re*
* Adjusted for hospital size, delivery and OB emergency experience, training to work as a team,
length of training and working in the same institute
RN L&D
Anesthesia
Pediatric
Other
P=0.06P<0.0001
P=0.004P=0.001
By Team
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Teamwork: Simulation
Established network to support hospitals
Develop a sustainable simulation program.
Develop Simulation Specialists
Access to simulation training opportunities
15 hospitals in the NPIC Simulation program attend training sessions, network, share ideas and information as they develop simulation programs in their organizations.
Simulation focus group
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Collaborative Structure
Work GroupCoach/Facilitator
Content Experts
Monthly Conference
Call
Collaborative Member Hospital Teams
Annual Patient Safety Symposium
Quarterly Topic of interest
Webinar
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Collaborative Learning: Webinars
Team Stepps
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Collaborative Structure
Work GroupCoach/Facilitator
Content Experts
Monthly Conference
Call
Collaborative Member Hospital Teams
Annual Patient Safety Symposium
Quarterly Topic of interest
Webinar
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Collaborative Learning: Annual Symposium
Collaborative Results
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Results
Variables Impacting reduction in claims frequency-
National impact-Tort reform
Increase awareness
Local patient safety efforts
Frequency & Severity by Injury Year for OB Providers
1
5 4
18
23
8
2426
33
25
33 3436
34
38
41
36 35
3234
20
11 10
3 20
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
0
5
10
15
20
25
30
35
40
45
DIRECT LOSS.... CLAIM_CNT
Oregon Rates 1983-2008
Northwest Physicians InsuranceOregon Rates by Year for OBG (Class 7/6), 1M/3M limits
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
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Physician Incentive 10% Premium Credit
Partnering with Harvard’s Risk Management Foundation and Advanced Practice Strategies, The Doctors Company is offering its physician members free of charge the online bundle of Perinatal courses. To qualify for the premium credit, physicians must complete the courses and implement a patient safety communication protocol plan in a 12-month period.
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Collaborative Funding
Annual Cost-2005 Consulting Costs—Includes all facilitation activities) $65,000
Includes travel, lodging and meals expenses, etc.
Conference call telephone and webinar charges $5,000
Annual OB Symposium (includes faculty/speaker fees) $17,000
Printed materials and mailings $2500
______
Total Annual Cost: $89,500
Total cost underwritten by NPIC
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Collaborative Funding
Annual Cost-2006-2007 2006 2007 Consulting Costs—Includes all facilitation activities) $65,000 $65,000
Includes travel, lodging and meals expenses, etc.
Conference call telephone and webinar charges $5,000 $ 5,000
Annual OB Symposium (includes faculty/speaker fees) $17,000 $17,000
Printed materials and mailings $2500 $ 2,000
Simulation Program $50,000 $ 38,000
______ ______
Annual Cost: $139,500 $127,500
Simulation Program offset by
Voluntary Sponsorship Support (-) $ 50,000 $30,000
Total Annual Cost _______ _______
$ 89,000 $ 97,500
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Collaborative Sustainability
Moving toward a sustainable funding model for the future. Hospitals are being asked to participate in a shared fee structure based on staffed beds according to the American Hospital Association annual report.
NPIC will continue to fund 50% of the collaborative costs with hospitals funding the remaining 50%.
Thank you
Questions
Contact Information
Marion Constable marconstable@cox.net
Kristine Larison kristine.larison@comcast.net
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