Excellence in Obstetrics

A MULTI-SITE AHRQ DEMONSTRATION PROJECT

Ann Hendrich, RN, PhD, F.A.A.NVice President, Clinical Excellence Operations

Executive Director, Patient Safety OrganizationSeptember 2011

Ascension Health

We are the largest Catholic health system, the largest private not-for-profit system and the third largest system (based on revenues) in the United States, operating in 20 states and the District of Columbia.

Facilities and Staff Locations

500+ Acute Care Hospitals 70

Available Beds 17,836

Physicians 30,000

Care of Persons Who Are Poor and Community Benefit $1 Billion

Financial Information (FY10)

Total Assets $18 Billion

Operating Revenue $14.8 Billion

Operating Income $569 Million

Net Income $1.2 Billion

Investment $723 Million

3

Ascension Health’s Vision

The Business Case for Perinatal Safety

Potentially Preventable Birth Injury Events

• 77 Birth Injury Events were reported as Claims between 7/1/04 to 1/1/06.

• 52 (68%) of the 77 Birth Injuries were potentially preventable based upon clinical review.

Known Birth Injury Events 7/1/2004 to 1/1/2006

Total Events = 77

Other = 23 30%

Brachial Plexus = 13

17%

Death = 2330%

Neurological Injury = 18

23%

6

The Business Case for Perinatal Safety

Malpractice Cost Projections• 76,000 Deliveries Per Year

• Approximately 30% of Exposures (Risk Adjusted) are Related to OB

• FY07 Obstetric Malpractice Expense was $36 Million

7

Demonstration Project Goals

1.Establish a uniform, evidence-based obstetrics practice model – Based on the idea that eliminating variability

in obstetrics practice will translate to improved patient safety

2.Implement a quick-response liability model– Include standardized practices for identifying,

reporting, responding to, investigating and disclosing medical errors and adverse outcomes

8

Demonstration Project Goals

3.Create the Ministry Intelligence Center (MIC)/OB Dashboard– IT infrastructure, portals, dashboards and

data warehouses – Provide target sites and central administration

with Key Performance Indicators – Allow ad hoc data queries and predictive

modeling capabilities

9

WhyHealing without Harm: A Multi-Site

Demonstration Project to Develop New Models for Medical Liability and Improve Patient Safety

Hypothe

sis 1 2 3 4 5

What

Decrease in

shoulder dystocia

injury rates and

infant harm

when the “bundle”

is introduce

d

Change in delays of treatment when fetal

distress occurs and an increase in cesarean

section effectivene

ss (necessity

and timeliness) when the protocol

guidelines are followed

Reduction in the

frequency and

severity (settlement amount) of

claims when full disclosure

is implement

ed

Increase in reporting of Serious

Safety Events when 5

elements of High

Reliability have been adopted

Decrease in all birth

trauma events

and rates

10

Healing without Harm – Year OneMajor Milestones

• 593 nurses/physicians trained on multiple interventions

• 5,800+ mothers consented between January-Septmeber 2011

• Average Consent Enrollment Rate at Five Sites– 88%

• Race/ethnicity breakdown of consented mothers– 59% White – 20% Black– 9% Hispanic– 2% Asian/Pacific– 2% Other– 7% Unknown

Healing without Harm – Year One Interventions for Clinical & Cultural

Change• Electronic Fetal Monitoring (EFM) e-learning

module– 202 physicians and 321 nurses trained

• Shoulder Dystocia Bundle and Training– Shoulder dystocia bundle tool developed

– 224 physicians and 349 nurses trained

• TeamSTEPPSTM and simulation training with hi-fidelity birthing simulators– 243 physicians and 414 nurses trained

• Coordinated communication (disclosure) training – 302 clinicians trained

• Cause Analysis training– 76 clinicians trained

Healing without Harm – Year One Interventions for Clinical & Cultural

Change

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Training Rates - Aggregate

EFM training - Physicians

EFM training - Nurses

Shoulder Dystocia training - Physicians

Shoulder Dystocia training - Nurses

Simulation Training - Physicians

Simulation Training - Nurses

Cause Analysis Training

Disclosure Training

Event Response Model

Obstetric Event Response Team Model

Risk Manager

Nurse

Coder

Neonate Provider

Obstetrician

System Reporting and Management

14

1/0

6-1

2/0

6

2/0

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/07

3/0

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/07

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/06

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8

AHRQ HANDS Perinatal Safety PerformanceBirth Trauma Rate

Site 1 Site 2 Site 3 Site 4 Site 5

Rolling 12-Month Period

Rat

e p

er 1

,000

Liv

e B

irth

s

July 2010Grant Start

1/0

6-1

2/0

6

2/0

6-1

/07

3/0

6-2

/07

4/0

6-3

/07

5/0

6-4

/07

6/0

6-5

/07

7/0

6-6

/07

8/0

6-7

/07

9/0

6-8

/07

10

/06

-9/0

7

11

/06

-10

/07

12

/06

-11

/07

1/0

7-1

2/0

7

2/0

7-1

/08

3/0

7-2

/08

4/0

7-3

/08

5/0

7-4

/08

6/0

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/08

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/08

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7-8

/08

10

/07

-9/0

8

11

/07

-10

/08

12

/07

-11

/08

1/0

8-1

2/0

8

2/0

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8-8

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10

/08

-9/0

9

11

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-10

/09

12

/08

-11

/09

1/0

9-1

2/0

9

2/0

9-1

/10

3/0

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/10

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/10

5/0

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9-8

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10

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0

11

/09

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12

/09

-11

/10

1/1

0-1

2/1

0

2/1

0-1

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0-6

/11

0.0

0.5

1.0

1.5

2.0

2.5

3.0

AHRQ HANDS Perinatal Safety PerformanceNeonatal Mortality Rate

Site 1 Site 2 Site 3 Site 4 Site 5

Rolling 12-Month Period

Rat

e p

er 1

,000

Liv

e B

irth

s

July 2010Grant Start