Excellence in Obstetrics: A Multi-Site AHRQ Demonstration Project (Text Version)
On September 19, 2011, Ann Hendrich made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (2.3 MB). Plugin Software Help.
Slide 1
Excellence in Obstetrics
A Multi-site AHRQ Demonstration Project
Ann Hendrich, RN, PhD, F.A.A.N.
Vice President, Clinical Excellence Operations
Executive Director, Patient Safety Organization
September 19, 2011
Slide 2
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.
Image: A map of the United States is shown with states; Ascension Health facilities locations are highlighted.
Facilities and Staff
Locations: 500+
Acute Care Hospitals: 70
Available Beds: 17,836
Physicians: 30,000
Financial Information (FY10)
Total Assets: $18 Billion
Operating Revenue: $14.8 Billion
Operating Income: $569 Million
Net Income: $1.2 Billion
Investment: $723 Million
Care of persons who are poor and community benefit $1 billion.
Slide 3
Ascension Health's Vision
Our Vision Realized
Healthcare That Works
Healthcare That Is Safe
Healthcare That Leaves No One Behind
For Life!
Inspired People.
Trusted Partnerships.
Empowering Knowledge.
Vital Presence.
Slide 4
Image: A line graph entitled "Ascension Health Priority for Action—Perinatal Safety. Birth Trauma (AHRQ Definition) - Rating 12 Month Average. 11/2006-6/30/2011" is shown.
Slide 5
Image: A line graph entitled "Ascension Health Priority for Action—Perinatal Safety. Neonatal Mortality - Rating 12 Month Average. 11/2006-6/30/2011" is shown
Slide 6
The Business Case for Perinatal Safety: Potentially Preventable Birth Injury Events
Image: A pie chart titled "Known Birth Injury Events: 7/1/2004 to 1/1/2006" is shown with the following data:
Other = 23 (30%)
Death = 23 ((30%)
Brachial Plexus = 13 (17%)
Neurological Injury = 18 (23%)
- 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.
Slide 7
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.
Slide 8
Demonstration Project Goals
- Establish a uniform, evidence-based obstetrics practice model:
- Based on the idea that eliminating variability in obstetrics practice will translate to improved patient safety.
- Implement a quick-response liability model:
- Include standardized practices for identifying, reporting, responding to, investigating and disclosing medical errors and adverse outcomes.
Slide 9
Demonstration Project Goals
- 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.
Slide 10
Image: Chart of Healing Without Harm:
Why | Healing without Harm: A Multi-Site Demonstration Project to Develop New Models for Medical Liability and Improve Patient Safety | ||||
---|---|---|---|---|---|
Hypothesis | 1 | 2 | 3 | 4 | 5 |
What | Decrease in shoulder dystocia injury rates and infant harm when the “bundle” is introduced | Change in delays of treatment when fetal distress occurs and an increase in cesarean section effectiveness (necessity and timeliness) when the protocol guidelines are followed | Reduction in the frequency and severity (settlement amount) of claims when full disclosure is implemented | Increase in reporting of Serious Safety Events when 5 elements of High Reliability have been adopted | Decrease in all birth trauma events and rates |
Slide 11
Healing Without Harm—Year One Major Milestones
- 593 nurses/physicians trained on multiple interventions.
- 5,800+ mothers consented between January-September 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.
Slide 12
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.
- TeamSTEPPS™ 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.
Slide 13
Healing without Harm—Year One Interventions for Clinical & Cultural Change
Image: A bar chart with aggregate training rates is shown.
Slide 14
Event Response Model
Image: The team involved in system reporting and management is shown: Obstetrician, Neonate Provider, Nurse, Coder, and Risk Manager.
Slide 15
Image: A chart titled "AHRQ HANDS Perinatal Safety Performance Birth Trauma Rate is shown. Five sites are involved.
Slide 16
Image: A chart titled AHRQ HANDS Perinatal Safety Performance Neonatal Mortality Rate is shown. Five sites are involved.