7/11/2012

1

IHI Expedition: Preventing Obstetrical Adverse Events

Deb Bell-Polson, MSN, RNC-OB

Peter Cherouny, MD

Sue Gullo, RN, BSN, MS

These presenters have nothing to disclose

Expedition Coordinator

2

Kayla DeVincentis, Project Coordinator, has

worked at IHI since 2009, starting as an intern in

the Event Planning department. Since then, Kayla

has contributed to the STAAR Initiative, the IHI

Summer Immersion Program, and the IHI

Expeditions. Kayla obtained her Bachelor’s in

Health Science from Northeastern University and

brings her interest in health and wellness to IHI’s

Health and Fitness team.

7/11/2012

2

3

WebEx Quick Reference

3

WebEx Quick Reference

• Welcome to today’s session!

• Please use Chat to “All

Participants” for questions

• For technology issues only,

please Chat to “Host”

• WebEx Technical Support:

866-569-3239

• Dial-in Info: Communicate /

Join Teleconference (in menu)

Raise your hand

Select Chat recipient

Enter Text

4

When Chatting…

Please send your message to

All Participants

7/11/2012

3

Our Expedition Director

5

Sue Leavitt Gullo, RN, BSN, MS, Managing Director,

Institute for Healthcare Improvement (IHI), brings 30

years of health care experience to her current roles,

which include work in IHI's national and international

patient safety work, and IHI's faculty for leadership and

patient safety. She is the Director of the Perinatal

Improvement Community and The Safer Patient Project

in Denmark. Prior to joining IHI, Ms. Gullo was the

Director of Women's Services at Elliot Hospital in New

Hampshire. Her prior nursing roles included experience

in the frontline clinical areas of maternal-child health,

oncology, and medical-surgical nursing. Ms. Gullo has

also been active as national faculty in obstetrical care

for the last 15 years. Her involvement with IHI dates

back to 1995 as a participant in the IHI Breakthrough

Series on Improving Maternal and Neonatal Outcomes

and continued as IHI faculty until she joined the IHI staff

in 2005.

Ground Rules

6

• We learn from one another – “All teach,

all learn”

• Why reinvent the wheel? - Steal

shamelessly

• This is a transparent learning

environment

• All ideas/feedback are welcome and

encouraged!

7/11/2012

4

Schedule of Calls

Session 1 – Introduction to Obstetrical Adverse Events

Wednesday, May 30, 1:00 PM – 2:30 PM ET

Session 2 – Structure and Process for System Redesign

Date: Wednesday, June 13, 1:30 PM – 2:30 PM ET

Session 3 – Executing Oxytocin Bundles

Date: Wednesday, June 27, 1:30 PM – 2:30 PM ET

Session 4 – Designing Reliable Processes

Date: Wednesday, July 11, 1:30 PM – 2:30 PM

Session 5 – Using the Perinatal Trigger Tool to Identify System Harm

Date: Wednesday, July 25, 1:30 PM – 2:30 PM

Session 6 – Results Report-out and Advanced Bundles

Date: Wednesday, August 8, 1:30 PM – 2:30 PM7

Faculty

8

Deb Bell-Polson, MSN, RNC-OB, is a Masters

prepared Perinatal Nurse with 22 years of experience.

Most recently has worked as a Clinical Nurse Manager

leading a multidisciplinary team that has had great

success in the IHI Perinatal Community. We had proven

results in changing culture for quality and safety and

achieving 95% compliance on the Elective Induction and

Augmentation bundles as well as the Vacuum Bundle.

Also serves on a regional Quality and Safety Network

guidelines team that is working to set regional standards

for care in the Northern New England region. Is most

recently a part of a state wide Committee to review

cases of Sudden unexplained infant Deaths and work to

prevent them in the future. When not working I keep

busy with my family of three sons and a wonderful

husband.

7/11/2012

5

Faculty

9

Peter Cherouny, MD, Professor of Obstetrics and

Gynecology, University of Vermont College of Medicine,

has strong clinical interests in obstetric health care

quality improvement and is currently serving as Chair of

the Institute for Healthcare Improvement's Perinatal

Improvement Community. He was also the lead author

of the IHI white paper, "Idealized Design of Perinatal

Care." He has been Chair of Quality Assurance and

Improvement and Credentialing for the Women's Health

Care Service of Fletcher Allen Heathcare for the last 15

years. His recent research and work in obstetric quality

improvement is as Chair of the March of Dimes

collaborative, "Improving Prenatal Care in Vermont,"

and as co-investigator of the MedTeams project.

Session Four

Designing Reliable Processes

10

7/11/2012

6

Mindful Practice

• It is not enough to do your bestyou must know what to do

and then do your best

�W. Edwards Deming

Designing Reliable Processes

• Do you have reliable processes?

• Do those processes achieve what you

want?

12

7/11/2012

7

If your process does not achieve what you expect, is it?

A Failure of……..

1. Will?

2. Ideas?

3. Execution?

13

http://www.ihi.org/knowledge/Pages/Tools/ExecutiveReviewofProjectsIHI.aspx

Failure of Will

• Resources necessary to the project’s success are not made available

• A few loud nay Sayers are blocking implementation and spread of good ideas

• Absence of any obvious connection between this project and key strategic goals

• Lack of executive and board attention to this project

• Line managers appear to be on the sidelines, not responsible for project success

14

7/11/2012

8

Failure of Ideas

• The project team has not gone outside the organization, or outside health care, to find the best ideas

• Few cycles of improvement have been attempted

• “Big Ideas” appear to be absent—changes being tested are safe, incremental, not radical redesigns

• The team can’t tell you who has the best results in the world on this topic

15

Failure of Execution

• Project setup, and project management

appear to be weak

• Preparation for spread is not part of the

project from the inception

• The project team can not articulate a

coherent change leadership framework

being used by the project

• The project gets good results on pilots, but

never seems to scale up16

7/11/2012

9

“What, exactly, are you trying

to accomplish in this project?”

17

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study DoSource:

Langley, et al. The Improvement Guide, 1996.

The three questions provide the strategy

The PDSA cycle provides the tactical approach to work

7/11/2012

10

The Sequence for Improvement

Spreading a change to other

locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and

Prediction

Test under

a variety of

conditions

Make part

of routine

operations

20

7/11/2012

11

21

1.Prevent failure (a breakdown in operations or functions).

2. Identify and Mitigate failure: Identify failure when it occurs and intercede before harm is caused, or mitigate the harm caused by failures that are not detected and intercepted.

3. Redesign the process based on the critical failures identified.

IHI uses a three-tiered strategy for designing reliable care

systems, with processes and procedures in place intended to:

Improvement Concepts Associated with Performance Resulting in 80-90% Process Reliability

(Primarily can be described as intent, vigilance, and hard work)

• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures

• Personal check lists

• Feedback of information on compliance

• Suggestions of working harder next time

• Awareness and training

7/11/2012

12

Prevent-Identify/Mitigate-Redesign 23

Any process stability?

Improvement Concepts Resulting in 95% Process Reliability

(Uses human factors and reliability science to design failure prevention, failure

identification, and mitigation)

• Decision aids and reminders built into the system

• Desired action the default (based on scientific evidence)

• Redundant processes utilized

• Scheduling used in design development

• Habits and patterns know and taken advantage of in the design

• Standardization of process

7/11/2012

13

Process/Structure/Outcome

1919-2000

Avedis Donabedian, M.D., M.P.H.

Structure and Process

• Create the sense of urgency─Deep Dive for data

• Define what to measure─Structure and process measures

7/11/2012

14

Vacuum Bundle

� Alternative labor strategies considered

� Prepared patient

�Informed consent discussed and documented

� High probability of success

�EFW, fetal position and station known

� Maximum application time and number of pop-offs predetermined

� Exit strategy available

�Cesarean and resuscitation team available

7/11/2012

15

Questions?

29

Raise your hand

Use the Chat

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.

30

7/11/2012

16

Plan• Compose aim

•Pose questions/predictions

•Create action plan to carry

out cycle (who, what, when,

where)

•Plan for data collection

DoStudy

Act

• Carry out the test and

collect data

•Document what occurred

•Begin analysis of data

• Complete data analysis

•Compare to predictions

•Summarize learning

• Decide changes to make

•Arrange next cycle

31

Principles & Guidelines for Testing

• A test of change should answer a specific question

• A test of change requires a theory and prediction

• Test on a small scale

• Collect data over time

• Build knowledge sequentially with multiple PDSA cycles for each change idea

• Include a wide range of conditions in the sequence of tests

32

7/11/2012

17

Repeated Use of the PDSA Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Sequential building of knowledge under a wide range of conditions Spread

33

Aim: Implement Rapid Response Team on non-ICU unit

Improved Communication

A P

S D

A P

S D

Cycle 1: ICU nurse responds to rapid response team calls on one unit,

one shift for one day

Cycle 2: Repeat cycle 1 for three days

Cycle 3: Have Respiratory Therapist attend

rapid response calls with ICU Nurse

Cycle 4: Expand coverage of RRT on unit

to one unit for one shift for five days

Cycle 5: Have Nurse Practitioner

respond to calls in addition to RT and

RN

Cycle 6: Expand rounds to

one unit for one shift seven

days a week

34

7/11/2012

18

Questions?

Raise your hand

Use the Chat

35

Storyboard Project

• Homework assignments for each call will

build on each other to create a

“storyboard” to present your progress

36

7/11/2012

19

Storyboard Explanation

• Intent: use this as an active tool over the year to

describe your work plan and improvements- successes

and barriers- and share your learning. Although you may

not have all of the measures currently in place, we have

included all of them in this template.

• “Building” storyboard” as you create the infrastructure

to achieve your aim, you will continuously expand this

template to share your journey.

• See notes on each slide for description of content.

37

Homework for Next Session

• Update your storyboard

─Complete as much as possible

38

7/11/2012

20

Expedition Communications

• If you would like additional people to

receive session notifications please send

their email addresses to

improvementmap@ihi.org.

• We have set up a listserv for the

Expedition to enable you to share your

progress. To use the listserv, address an

email to OBExpedition@ls.ihi.org.

39

Next Session

Session 5 – Using the Perinatal Trigger Tool to Identify System Harm

Date: Wednesday, July 25, 1:30 PM – 2:30 PM

40