Excellence in Obstetrics: A Multi-Site AHRQ Demonstration Project (Text Version)

Slide presentation from the AHRQ 2011 conference.

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

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

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

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

 Ascension Health Priority for Action-Perinatal Safety

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

 Ascension Health Priority for Action-Perinatal Safety

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

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

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

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.

Slide 9

 Demonstration Project Goals

Demonstration Project Goals

  1. 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

 Healing Without Harm

Image: Chart of Healing Without Harm:

WhyHealing without Harm: A Multi-Site Demonstration Project to Develop New Models for Medical Liability and Improve Patient Safety
Hypothesis12345
WhatDecrease in shoulder dystocia injury rates and infant harm when the “bundle” is introducedChange in delays of treatment when fetal distress occurs and an increase in cesarean section effectiveness (necessity and timeliness) when the protocol guidelines are followedReduction in the frequency and severity (settlement amount) of claims when full disclosure is implementedIncrease in reporting of Serious Safety Events when 5 elements of High Reliability have been adoptedDecrease in all birth trauma events and rates

Slide 11

Healing Without Harm-Year One Major Milestones  

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 and Cultural Change  

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 and Cultural Change

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

Event Response Model

Image: The team involved in system reporting and management is shown: Obstetrician, Neonate Provider, Nurse, Coder, and Risk Manager.

Slide 15

AHRQ HANDS Perinatal Safety Performance Birth Trauma Rate  

Image: A chart titled "AHRQ HANDS Perinatal Safety Performance Birth Trauma Rate is shown. Five sites are involved.

Slide 16

AHRQ HANDS Perinatal Safety Performance Neonatal Mortality Rate  

Image: A chart titled AHRQ HANDS Perinatal Safety Performance Neonatal Mortality Rate is shown. Five sites are involved.

Page last reviewed March 2012
Internet Citation: Excellence in Obstetrics: A Multi-Site AHRQ Demonstration Project (Text Version). March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/hendrich/index.html