Maternity Quality Matters Award Luncheon. Seton Family of Hospitals

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1 Maternity Quality Matters Award Luncheon H O N O R I N G Seton Family of Hospitals

2 What would you do to make the world a better place? It takes a lot of commitment to make a difference in the lives of others. What fuels the commitment is a strong belief that things can change and people s lives can improve. UnitedHealthcare salutes the Seton Family of Hospitals for their dedicated actions to make this belief a reality. In recognition of their efforts, the Seton Family of Hospitals has been named the inaugural winner of the Maternity Quality Matters Award for their dedication to providing quality care and focused attention to the women and children it serves. unitedhealthcare.com 2009 United HealthCare Services, Inc. Insurance coverage provided by or through United HealthCare Insurance Company or its affiliates. Health plan coverage provided by or through UnitedHealthcare of the Mid-Atlantic, Inc.

3 April 3, 2009 Dear Colleagues, Welcome to our 90th anniversary symposium luncheon and presentation of the inaugural Maternity Quality Matters award to the Seton Family of Hospitals. Childbirth Connection is proud to congratulate Charles Barnett, CEO, Frank Mazza, Chief Patient Safety Officer and Associate Chief Medical Officer, and members of the interdisciplinary Seton Perinatal Safety Team for their impressive maternity care quality improvement programs. They have implemented clinical processes to eliminate birth trauma and preventable maternal injury, reduced rates of overused procedures, sustained continuous improvement, and dramatically decreased liability premium costs. This award program further describes results of Seton s efforts. We hope that this award and Seton s fine example encourage others to initiate maternity care quality improvement programs that meet the needs of women and babies in their communities. We are most grateful to UnitedHealthcare for its generous support of the Maternity Quality Matters award and this symposium. We also wish to thank the award jurors including Suzanne Delbanco, Barbara Fildes, Paul Gluck, Donna L. Lynne, Linda Mayberry and Jeffrey Quinlan, for reviewing and scoring award applications, many of which are briefly described in this program. Congratulations to all the applicants for their efforts to improve the quality of maternity care. Lastly, we wish to thank each of you for participating in this landmark policy symposium, Transforming Maternity Care: A High Value Proposition, and welcome your continued involvement in developing and implementing a Blueprint for Action to improve the structure, process and outcomes of maternity care. Together we will improve the quality and value of maternity care for all women, babies and families. Sincerely, Patricia Troy President Board of Directors

4 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D L U N C H E O N P R O G R A M 12:00-1:00 PM Luncheon 1:00-1:15 PM Welcome and Opening Remarks Maureen P. Corry Executive Director Childbirth Connection Award Sponsor Remarks Pamela Stahl Senior Vice President, Women s Health Line of Service UnitedHealthcare Recipient Presentation and Remarks Frank Mazza, MD Chief Patient Safety Officer and Associate Chief Medical Officer Seton Family of Hospitals Concluding Remarks Maureen P. Corry

5 A B O U T T H E M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D The inaugural Maternity Quality Matters Award is presented to an organization demonstrating significant improvement in maternity care quality through measurement of performance, incorporation of evidence-based practice, and responsiveness to needs of childbearing women and families, among other criteria. Our panel of judges represented experts in both health care quality and service provision. Our panel of jurors includes: Suzanne F. Delbanco, PhD President, Health Care Division Arrowsight, Inc. Barbara Fildes, MS, CNM, FACNM American College of Nurse-Midwives Assistant Professor, Obstetrics and Gynecology, Dartmouth Medical School Paul A. Gluck, MD Immediate Past Chair of the Board, National Patient Safety Foundation Associate Clinical Professor, Department of Obstetrics and Gynecology University of Miami Miller School of Medicine Donna L. Lynne, DrPH President Kaiser Foundation Health Plan of Colorado Linda Mayberry, PhD, RN, FAAN Association of Women s Health, Obstetric and Neonatal Nurses Associate Adjunct Professor, College of Nursing, New York University Jeffrey D. Quinlan, MD Assistant Professor of Family Medicine, Uniformed Services University of Health Sciences Chair, American Academy of Family Physicians Advanced Life Support in Obstetrics Advisory Board

6 W I N N E R O F T H E M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D The Seton Family of Hospitals, a major healthcare network and ministry market of Ascension Health, the largest Catholic and not-for-profit system in the United States, has served the Central Texas region for more than a century. From a single infirmary built at the dawn of the 20th century, Seton has grown into one of the nation s top health care systems, with five urban acute care hospitals, a pediatric medical center, the region s only inpatient mental health facility, a level II trauma center, two rural hospitals and several community health clinics. Four of the urban hospitals maintain Magnet nursing designation by the American Nurses Credentialing Center. Five facilities offer maternity services averaging 9,800 live births per year, and the Family maintains three Level III NICUs. The Central Texas region has been a hotbed of explosive growth, and Seton s 11-county service area now is home to more than one-and-a-half million people. In 2002, Ascension Health unveiled a bold five-year system-wide goal of achieving zero preventable deaths and injuries among its hospitalized patients nationally (by 2008). To achieve this transformation, Ascension s Clinical Excellence team identified eight, so-called Priorities for Action (PFA). One of those was to eliminate both birth trauma and preventable maternal injury via a Perinatal Safety PFA. Seton s Perinatal Safety Work Group (PNS) was originally chartered in 2003 as an alpha project by Ascension to develop and define new processes that were transformational in the Perinatal clinical area in an effort to reach those goals. Under the direction of senior leadership and the auspices of an interdiscipliary team, the membership committed to fashioning the PNS in the model of a high reliability organization and began implementing numerous evidence-based best practices. Enhanced monitoring, strict documentation requirements, physician quarterly report cards, the creation of a team culture all became top priorities. Frontline staff were empowered to stop the line when agreed-upon best practice rules were threatened (for example, elective induction of delivery prior to 39 weeks was strictly forbidden). A critical element was the creation, with the help of the Institute for Healthcare Improvement, of new Perinatal Safety bundles sets of connected, evidence-based steps to be followed all the time, every time, by each team member. Beyond the strictly clinical metamorphosis, Seton also transformed the educational and emotional aspects of childbirth. A primary goal was to create a climate which encouraged informed decision-making by patients and their families. During the admissions process,

7 30% 25% 20% 15% 10% 5% 0% 19.4% 20.5% FY01-FY03: Mean = 16.2% 17.3% 17.8% 15.8% 16.3% 14.3% 15.6% Episiotomy Rate Seton Family of Hospitals 7/1/ /31/2008 (episiotomy / total vaginal deliveries) 14.4% 14.1% 15.7% Perinatal Safety Initiatives started 12.6% 13.1% 12.3% 11.5% FY04-FY06: Mean = 13.1% 15.6% FY07-FY09: Mean = 9.5% 14.1%14.2% 13.7% UCL 13.2% 13.2% 2s 12.6%12.8% 1s 11.7% 11.3% 10.5% 1s 10.0% 9.1% 9.7% 10.1% 2s 9.2% LCL 8.3% 8.1% 8.0% FY01-Q1 FY01-Q2 FY01-Q3 FY01-Q4 FY02-Q1 FY02-Q2 FY02-Q3 FY02-Q4 FY03-Q1 FY03-Q2 FY03-Q3 FY03-Q4 FY04-Q1 FY04-Q2 FY04-Q3 FY04-Q4 FY05-Q1 FY05-Q2 FY05-Q3 FY05-Q4 FY06-Q1 FY06-Q2 FY06-Q3 FY06-Q4 FY07-Q1 FY07-Q2 FY07-Q3 FY07-Q4 FY08-Q1 FY08-Q2 FY08-Q3 FY08-Q4 FY09-Q1 FY09-Q2 FY-Qtr num/den rate FY01-Q1 388 / % FY01-Q2 413 / % FY01-Q3 327 / % FY01-Q4 347 / % FY02-Q1 333 / % FY02-Q2 352 / % FY02-Q3 276 / % FY02-Q4 310 / % FY03-Q1 303 / % FY03-Q2 283 / % FY03-Q3 292 / % FY03-Q4 252 / % FY04-Q1 255 / % FY04-Q2 240 / % FY04-Q3 245 / % FY04-Q4 272 / % FY05-Q1 234 / % FY05-Q2 222 / % FY05-Q3 196 / % FY05-Q4 191 / % FY06-Q1 218 / % FY06-Q2 227 / % FY06-Q3 207 / % FY06-Q4 186 / % FY07-Q1 192 / % FY07-Q2 195 / % FY07-Q3 138 / % FY07-Q4 157 / % FY08-Q1 188 / % FY08-Q2 174 / % FY08-Q3 155 / % FY08-Q4 119 / % FY09-Q1 150 / % FY09-Q2 117 / % Seton began requiring its physicians to provide and fully document information File: Episiotomy regarding Rate_SFH.xls Printed: 3/13/09 risks, benefits, and reasonable alternatives for all scheduled procedures such as inductions and cesarean sections. Posters and other informational tools which transparently outlined the perinatal safety initiatives and performance indicators became prominent in the Labor & Delivery areas. Childbirth classes were fortified with sections on informed decisionmaking and performance goals. With the benefit of continuous small tests of change, rigorous outcomes measurement, and the relentless oversight of the Perinatal Safety Team, the transformational effort gained steady momentum and birth trauma numbers commenced a steady decline. By the end of FY 2008, the Seton had accomplished a 93 percent reduction in the birth trauma rate, from a frequency of 0.3% (or 3 per 1,000) to 0.02% (or 0.2 per 1,000); the practice of elective induction prior to 39 weeks was effectively eliminated; and statistically significant reductions in instrumented delivery rate (from 7.5% to 4.6%), episiotomy rate (from 16.2% to 9.5%), and the frequency of iatrogenic prematurity (from 0.25% to 0.17%) were all successfully accomplished, and have been sustained. The business case for perinatal safety has been impressive as well, with perhaps the most dramatic result being the reduction on Seton s malpractice premium from $24 million to $10 million per year throughout the five year period that the PNS has been at work. For its efforts, in 2007, Seton s Perinatal Safety Workgroup gained national attention as one of only four acute care facilities nationally to receive the Joint Commission s coveted Ernest Amory Codman Award for excellence in performance improvement.

8 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S Childbirth Connection congratulates all of the 35 award applicants for their efforts to provide high quality maternity care. Below are brief descriptions of their programs, along with contact information. We hope they spark more ideas and innovation to foster maternity care quality improvement. Alexian Brothers Medical Center Located in the Chicago northwest suburbs, Women & Infant Services of Alexian Brothers Medical Center delivers approximately 2700 newborns each year. The facilities include ten LDRs, a separate postpartum area and a Level II plus nursery. Our department supports the family centered model of care where the infant and mom are kept together throughout their stay. The majority of our postpartum moms participate in our self-medication program, where analgesic medication for pain management is kept at their bedside. Additional services include prenatal and postnatal education classes, lactation services, a perinatal bereavement program, and follow-up phone calls to families post discharge. Our department utilizes clinical pathways and algorithms to facilitate care for vaginal and cesarean deliveries, as well as, our special care nursery infants, and normal newborns. Our departmental policies reflect current evidenced-based care. We are actively involved in quality improvement activities, such as, the Institute for Healthcare Improvement Perinatal Innovation Community, scoring a 4 out of a possible 5 on IHI s sustained improvement scale. Our department also supports Joint Commission s National Patient Safety Goals and utilizes Press Ganey survey results for ongoing process improvement work. Contact: Linda Fournier, DNP, RNC-OB, APRN, Clinician III, Women & Infant Services; fourniel@alexian.net; American Academy of Family Physicians The American Academy of Family Physicians (AAFP) Advanced Life Support in Obstetrics (ALSO ) program, in cooperation with the US Department of Defense Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program, has developed the ALSO Patient Safety Program. This program presents an affordable and cost-effective team training curriculum geared toward hospital teams providing maternity care services, with a focus on evidence-based interventions designed to reduce maternal and infant harm. Utilizing realistic maternity patient emergency simulations based on the AAFP s highly successful ALSO Provider Course, the ALSO Patient Safety Program will equip participating institutions with tools for ongoing periodic performance evaluation and promote access to realistic internal and external benchmarking data for purposes of ongoing performance improvement. Contact: Diana Winslow RN, BSN, Manager, ALSO Program; ; dwinslow@aafp.org The Birth Center, A Nursing Corporation The Birth Center is the only licensed, freestanding, birth center in the Sacramento, California area. Following the midwifery model of care, it believes that pregnancy and birth are normal, healthy events. Birth Center s mission to create a place for listening and relationship building, where control belongs to the families, and where choices are honored to create a place where safety for those served is the highest priority.

9 Birth is experienced in the comfort of a home-like atmosphere, with a bedroom, birthing tub, private bathroom, and family room for labor and birth. Emergency equipment is tastefully hidden but easily accessible. No narcotics are available, and interventions are rare to none. All births are attended by a Certified Nurse Midwife, Registered Nurse, and Doula. With a small staff and no more than 10 births per month, The Birth Center is able to provide personalized care, with staff-client relationships established far prior to labor. Safety is always the highest priority. Rare transfers go smoothly. The c-section rate for 2007 was 3%. With over 250 births in its 9-year history, the maternal and newborn mortality rate is 0%. The Birth Center s services include the following: Prenatal care Birth care, including doula assistance and water birth Breastfeeding support Post-partum care Well-women gynecology Milk-banking Contact: Ruth Cummings, CNM, Director; ; BlueChoice HealthPlan BlueChoice HealthPlan serves approximately 194,000 members located primarily in South Carolina, and is NCQA accredited. The maternity program, Great Expectations + Maternity, was implemented in Its primary goal is to help members take steps toward a healthier pregnancy with educational mailings and telephonic outreach, support and monitoring. The staff is comprised of clinically experienced maternity nurses who encourage healthy self-care behaviors and promote the physician-patient relationship. Members are automatically enrolled in the program at no charge upon notification of pregnancy from their physician; however, they may opt out at any time. Program outreach includes: 1. An initial maternity packet, including a detailed health assessment with a maternity book offered as incentive for completion. 2. An outbound telephone call to members during each trimester of enrollment and unlimited inbound calls during the pregnancy. 3. Additional telephonic monitoring and service coordination with the physician by a maternity nurse case manager for eligible members who are determined to be high risk. 4. Additional educational materials, as needed, on special concerns of and chronic conditions during pregnancy. 5. Referrals to internal health and disease management programs. 6. Referrals to external prenatal programs, community agencies, health education classes and support resources. 7. A phone call to members with targeted chronic diseases from our maternity staff after delivery. 8. Web site information, tools and resources for members and physicians. 9. Active staff collaboration with community leaders who are addressing prenatal care in South Carolina. Contact: Marie Fox; marie.fox@bluechoicesc.com

10 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S California Maternal Quality Care Collaborative (CMQCC) Principal Investigator: Elliott Main, MD Executive Director: Debra Bingham, DrPH, RN The California Maternal Quality Care Collaborative (CMQCC) is a data-driven, Quality Improvement (QI), multi-stakeholder organization devoted to eliminating preventable maternal death and injury in California. To achieve this mission, CMQCC leaders, e.g., physicians, nurses, public health leaders, consumers, payors will continue to work together to: Define and implement best practices for public health, communities, women with quality, safety, and social justice as the clear priorities of every decision and action. Promote communication and collaboration between all maternity stakeholders. Gather, review, and organize maternity data and statistics into actionable information. Build the next generation of maternal health leaders to continue the growth and scope of CMQCC. CMQCC was formed in July 2006 by the California Department of Health, Maternal Child and Adolescent Health Division, and the California Perinatal Quality Care Collaborative (CPQCC). California Pregnancy-Associated Maternal Mortality Review (CA-PAMR) Committee: In February 2007, the Maternal Child and Adolescent Health Division and CMQCC formed CA-PAMR. The linkage of mortality reviews to CMQCC, is an innovative approach that facilitates the translation of review findings (data) into action projects. State-Wide Hospital Action Project: Obstetric hemorrhage was one of the most common causes of maternal mortality with a strong chance to alter outcomes. Thus, a state-wide action project is underway to improve clinicians Readiness, Response, Recognition, and Reporting of Obstetric Hemorrhage. Four Local Assistance for Maternal Health (LAMH) Pilot Projects: LAMH was started in September of Four counties are implementing projects. Los Angeles: Reducing Maternal Hemorrhage: A Multi-Tiered Approach San Bernardino: Maternal Morbidity and Mortality Education on Labor Induction Project San Diego: Woman-Carried Prenatal Record Cards Ventura: Healthy Interconception Project (VCHIP) Contact: Catholic Healthcare West The Goal of the Perinatal Pursuit of Excellence was to achieve breakthrough improvements and best practice in the Perinatal setting to eliminate unnecessary harm and improve outcomes for our patients. The Pursuit of Excellence was implemented by all 32 perinatal care units within Catholic Healthcare West (CHW) comprising 326,000 deliveries over five years in California, Arizona and Nevada. To progress toward this goal, several actions were implemented over the course of three years.

11 Initiatives for the Perinatal Pursuit of Excellence focused on examining processes and systems and implementing steps that have been shown to reduce patient injuries and provide quality care in perinatal services. The three clinical initiatives implemented were: Medteams Crew Resource Management This program which has been validated as a method for improving teamwork and safety. National Certification Corporation (NCC) Testing A subspecialty Exam in Electronic Fetal Monitoring test used to prevent birth-related injury to infants through validation and maintenance of competency standards in the Labor and Delivery setting. Executive WalkRounds A simple management tool designed to assist hospital leaders in implementing effective solutions for promoting safety. Hearing the concerns of frontline providers, supporting concepts of appropriate accountability, and allocating resources. Nearly 900 WalkRounds occurred over 2 years and over 4,500 action items resulted. Over 3,600 employees and physicians were trained in MedTeams principles thus improving communication between care providers. Over 1,200 nurses and physicians participated in the National Certification Corporation (NCC) certification test to demonstrate knowledge in interpretation of and interventions for electronic fetal monitoring. Contact: Brenda Chagolla RNC, MSN, CNS, Manager, Patient Safety and Clinical Risk Specializing in Maternal and Child Services; Brenda.Chagolla@chw.edu; Centering Healthcare Institute The Centering Healthcare Institute (CHI) is a nonprofit organization whose work is to promote the Centering model of group health care. The model has three components: health assessment, education, and support and is appropriate for anyone seeking health and preventive care. Centering is a rewarding way for patients to participate in their care. Group participants spend more time with their provider and with others with similar health concerns, giving them an opportunity to learn together and from each other. Check-ups, education/ skills building, and development of community all occur within the group setting. CenteringPregnancy is the signature model developed in by Sharon Rising, a nurse-midwife. Now there are over 300 sites in almost every state and some foreign countries. This model provides complete prenatal care throughout pregnancy for groups women of similar gestation. CenteringParenting piloted in 2005 continues the groups for the first year of life and beyond, providing both well-baby and well-woman care. Lifecycle groups, especially CenteringDiabetes, are in development. Outcomes for people getting care in groups are better than in traditional care. In a randomized control trial conducted through Yale University, 1047 women were randomized to traditional or group care. There was a 33% reduction in preterm birth for women in Centering groups. In addition, satisfaction was significantly higher; there were increased breast-feeding rates and improved knowledge and readiness for birth and parenting. The Centering model responds to the Institute of Medicine s Rules for Redesign of healthcare and is truly on the forefront of health care reform. Contact: Sharon Rising, Executive Director; srising@centeringhealthcare.org

12 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S East Jefferson General Hospital Can Nursing Effect Medical Practice Regarding Elective Induction? In response to recognition of increasing issues surrounding elective inductions, Woman & Child Services at East Jefferson General Hospital in Metairie, Louisiana, sought to provide data to support a change in medical practice regarding elective inductions. The literature search supported our theory that limiting elective inductions to 39 weeks of gestation on the anticipated date of delivery, and scheduled only two weeks prior to the date of the induction would decrease the challenges surrounding near term deliveries. Our data collection was an examination of total number of deliveries, number of elective repeat cesarean sections, number of elective inductions, number of elective inductions resulting in primary cesarean sections, and number of admissions to the NICU following elective inductions. We found our elective induction rates were both higher than national benchmarks, as well as inconsistent with adherence to professional guidelines. After presenting the findings to our multi-disciplinary Perinatal Work Team and OB section, the decision was made to require an induction indication if an elective induction was scheduled for less than 38 weeks. Encouraged, but not satisfied, we continued our process examining specific data on elective inductions less than 38 and less than 39 weeks to illustrate improvement, but continued challenges. The data spoke for itself and on December 2007, the OB section unanimously adopted adherence to the guidelines of only scheduling elective inductions only two weeks prior to delivery for delivery at least 39 weeks gestation. The change was implemented in January Contacts: Barbara Carson, RNC Ob, IBCLC, LCCE, Supervisor, Woman & Child Clinic, Woman & Child Services; bcarson@ejgh.org; Lisa Hickey, RNC Ob, BSN, Nurse Educator, Woman & Child Services; lhickey@ejgh.org Gila Regional Medical Center The First Born Program (FBP) provides mothers, fathers, and primary care providers with education and support to encourage healthy pregnancies, preparedness for labor and birth, breastfeeding and development of healthy babies. The FBP is sponsored by Gila Regional Medical Center, a private, nonprofit county hospital. The FBP began in 1996 in response to the following needs identified by the Grant County Community Health Council: health disparities both during pregnancy and in the early development of first born children low birth weight prevalence of abuse The FBP supports the premise that a healthy pregnancy and childhood are critical to the well-being of children and also basic to building resilient families and healthy communities. All services are available at no cost to all first-time families, including adoptive families. Services may begin at any time during pregnancy or at the birth of the baby and continue until the child is three years of age, or until family goals are achieved. Home visits are provided weekly or as needed by degreed and non-degreed staff who are diverse in age, culture, ethnicity, language, education, and experience. In addition, all families are offered a post partum visit by a registered nurse. Contact:

13 Group Benefit Services Better Beginnings Plus is a national telephonic maternity program designed to promote the best possible outcomes for expectant mothers and their babies through identification, screening, education, monitoring, and care coordination by a case manager. The program starts with an introductory mailing that includes a member Prenatal Self-Assessment that we ask that the expectant mother to complete. A high return rate is promoted by offering the expectant mother a small gift for participation. The case manager carefully reviews each assessment, stratifying them into healthy and at-risk populations. She also works closely to obtain input from the health care provider, designing case management interventions to support the medical plan of care and meet each individual s health care needs. Each participant is sent a series of educational mailings designed to promote the health and well-being of the mother and her unborn baby and are carefully timed to coincide with certain pregnancy milestones. A final mailing that focuses on the mother s recovery and safe infant care is sent once delivery is confirmed. Measure Nat l. Avg. Early prenatal care 96.2% 95.1% 97.0% 83.7% Low birth weight 4.5% 4.0% 2.6% 8.2% Preterm births 5.1% 5.0% 4.6% 12.7% NICU admit rate 9.0% 7.8% 5.9% 11.0% NICU ALOS (days) From 2006 through 2008, participants had 99.99% satisfaction with the program. Contact: Kimberly Babaie, RN, BSN, CCM, Director of Care Management Group Benefit Services, Inc.; kbabaie@gbsio.net; Intermountain Nurse Midwives The mission of the Intermountain Healthcare Community Prenatal program is to expand access to perinatal care, improve birth outcomes and breastfeeding rates for underserved women. Although all women are welcome, the primary group served is Spanish-speaking, immigrant, low income, uninsured women. Specifically the goals are to: 1) Provide adequate perinatal care according to ACOG guidelines 2) Decrease low and very low birth weight infants 3 Decrease Cesarean delivery rates, both primary and repeat, without increasing maternal or infant morbidity 4) Decrease obstetric trauma of 3rd and 4th degree lacerations 5) Increase breastfeeding rates This community-based program provides prenatal, delivery and postpartum care by the Certified Nurse-Midwives (CNM s) of Intermountain Nurse Midwives, coupled with perinatalogy consultation and co-management from the Intermountain Maternal-Fetal

14 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S Medicine physicians. This partnership enables seamless care for both low and high-risk obstetric patients. This alliance partnered with the Intermountain Healthcare School and Community Clinics, who provide low-cost healthcare to the uninsured and believe strongly that improving the health of childbearing women improves the health of the entire community. Care is provided at two clinic sites, Neighborhood Clinic and the Rose Park Clinic. Care is evidence-based, culturally driven and focused on the mother and newborn dyad within the context of her familial support. Births are attended by the CNM s at Intermountain Healthcare Hospitals. CNM s provide bedside support throughout labor. Outcomes for the women cared for in this program were better than both national and state data for Hispanic women. Contact: Angela Anderson, CNM, Director; Angela.anderson@imail.org Kaiser Permanente Northern California Early Start Early Start is an outpatient clinic-based perinatal substance abuse intervention program located in Kaiser Permanente Northern California region. Early Start provides pregnant women with universal screening and early identification of substance abuse problems. This includes an assessment, education, early intervention, ongoing counseling and case management by a licensed clinical therapist with expertise in substance abuse. This clinician, or Early Start Specialist (ESS), is physically stationed in the prenatal clinic in a confidential office space. All pregnant patients complete a self-administered questionnaire that screens for risk of alcohol, tobacco and illicit drug use during pregnancy. With consent, patients provide a urine sample for toxicology testing of nine drugs of abuse. Women found to be at risk are scheduled for an assessment with the ESS. This visit occurs in conjunction with the regular prenatal care visit. The ESS completes a thorough psychosocial assessment with the patient, educates her about risks, and provides support, resources and referrals. Follow-up Early Start appointments occur throughout the pregnancy in conjunction with the medical prenatal visit. The goals are to decrease substance use in pregnant women, reduce negative birth outcomes and medical costs associated with prenatal substance abuse, improve access to substance abuse services for pregnant women, and enhance provider satisfaction and efficacy. Research has shown that babies of women who have received treatment in Early Start have significantly better birth outcomes (decreased ventilation, low birth weight, preterm delivery, placental abruption, and intrauterine fetal demise), than babies of women who did not receive treatment in Early Start. Contact: Maternity Care Coalition MOMobile at Riverside Correctional Facility Helping women to still be Mommy even behind bars, that is why MOMobile is at Riverside Correctional Facility. Maternity Care Coalition (MCC) is a private nonprofit organization founded in For over 20 years, MCC s signature MOMobiles have brought a host of supportive services directly into the homes and communities of families throughout the city of

15 Philadelphia and surrounding counties through providing advocacy and case management by well trained case managers called Family Advocates. The MOMobile at Riverside Correctional Facility for Women (RCF) began operations in November The program is housed within RCF with three full-time staff. It is the only program of its kind in Pennsylvania. MOMobile clients at RCF struggle with multiple complex and often chronic problems such as substance abuse, mental heath concerns and histories of abuse and trauma, in addition to issues within the criminal justice system. MCC helps the women in the program acquire the resources, understanding, and parenting skills to establish healthy families as they make the transition from prison to home. The program provides the following services: peer-educational groups for prenatal and postpartum clients, individual case management services during incarceration, transitional case management up to a year following the client s discharge, and doula or labor support services before, during, and just after birth for clients who are incarcerated. To date, The MOMobile at Riverside has served over 200 women and attended 18 births since the start of the doula initiative in May Of the women served only 33 women have returned to Riverside Correctional Facility. Contact: Danyell Williams, MCJ, Program Manager; ; dwilliams@momobile.org New Hanover Regional Medical Center The goal of Families First is to provide family centered care to obstetrical patients by keeping moms, dads and term newborns together following non-emergent cesarean section. Keeping moms and newborns together will increase bonding, allow breastfeeding infants to nurse during the first hour of life, and increase patient satisfaction. Patient surveys revealed that mothers who had a cesarean section often complained of not seeing their infant until 2-3 hours of age. In preparing to move to a new building, the staff made a goal to keep stable infants born after a non-emergent cesarean section with their mother in the PACU. Our new PACU was designed for family centered care. Space was allocated so that there would be ample space for families, staff and patients. The room is stocked with supplies to care for both mom and newborn and was designed so that infants can receive their first bath in the PACU. In the first phase, we are targeting all stable, non-emergent cesarean section infants that are born during the day to go to the PACU with their mother. As we work though the process, we will expand to offer this service at night. Data: Press Gainey Patient Satisfaction Score: Goal 65 % September 27% October (Implementation month) 66% November 95% December 99% Contact: Hannah Brownlow, RN, Perinatal Innovations Coordinator, Women s Services; ; hannah.brownlow@nhrmc.org

16 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S Paul and Judy Andrews Women s Hospital The Paul and Judy Andrews Women s Hospital is a 110 bed women s center connected to Baylor All Saints Medical Center, a full service acute care hospital. Planned, designed and built just for women, Andrews Women s Hospital provides advanced care for every phase of a woman s life. In short, the Andrews Women s Hospital represents the best thinking in women s health care today, concentrated in a world-class facility and backed by the strength and commitment of Baylor Health Care System, Baylor All Saints Medical Center and our dedicated community. Services include complete maternity care with OB triage, antenatal testing, surgical services, breast services with RN navigator, genetic testing, pelvic and urogynecologic medicine, reproductive medicine, perinatal services & neonatal intensive care unit. This facility offers 25 labor rooms, 64 bed postpartum and 64 bed well baby nursery, 63 bed Level III NICU, & 28 bed antepartum unit. The Andrews Midwife Center, which serves our underprivileged and disadvantaged women in our community and surrounding counties provides family planning, well-woman gynecology, prescriptions, prenatal care, labor and delivery management, pain management including epidural anesthesia, and social services. This clinic has 4 certified nurse midwives under the supervision of a board-certified ob/gyn. Contact: Janice Whitmire, Administrator; ; Janicewh@baylorhealth.edu San Francisco General Hospital At San Francisco General Hospital (SFGH), the Nurse-Midwifery service provides prenatal care in a unique CenteringPregnancy /Community-Based Organization collaborative. CenteringPregnancy (CP), a group-based model that takes women out of exam rooms and into group space for prenatal care, brings together women of similar gestational age who go through pregnancy together in a setting that provides integrated assessment, health education and social support services. CP has been used at SFGH since 1999 with both recent immigrant Latina and English-speaking adolescent populations. CP is an empowerment model, and among its goals is facilitation of development of a heightened sense of authority over health care decisions, including decisions around use of social services. In an effort to improve access to social services among CP clients, in 2004 we initiated the first of three collaborative partnerships between our CP programs and local CBOs. In each collaborative, the nurse-midwife from SFGH partners with an employee of the CBO and together they lead groups physically based at the CBO. What benefit have we seen through these partnerships? One result has been improved cultural congruence between group leaders and clients, as CBO employees are more often of similar cultural background to participants than clinic staff. We have also observed a significant increase in use of CBO services, compared with both traditional and CP prenatal care clients receiving care at the clinic. Lastly, the newly-forged relationships between agencies and among staff have benefited all, as together we feel we are providing improved care for our clients. Contact: Margy Hutchison, CNM, Director of Centering Pregnancy Programs; hutchisonm@obgyn.ucsf.edu

17 Sentara Health Care The Ob Right Program is a patient safety initiative designed and piloted by a multidisciplinary team at Eastern Virginia Medical School, Sentara Norfolk General and Leigh Hospital beginning in The mission of the program is: Minimizing the risk of iatrogenic injury to the mother and the fetus Reduction of adverse patient safety events in the Labor & Delivery area Decrease professional liability exposure Increase teamwork, and communication to affect optimum clinical outcomes. Two guiding principles have underscored all aspects of the program: Use applicable evidence and/or published standards and guidelines When a clinical choice is presented...choose patient safety rather than production During the pilot period of the Ob Right Program, a comprehensive and deliberate program was designed and implemented including: Web-based interactive teaching modules for physicians and nurses in interpretation of fetal heart rate patterns Clinical protocols for elective induction of labor, elective cesarean section, recognition and management of uterine tachysystole, universal cord ph collection and universal monitoring of maternal heart rate during labor Revised documentation and consents including adoption of the NICHD clinical definitions of fetal heart rate tracing patterns, standardized and simplified Oxytocin order set Fostering a culture of safety by encouraging reporting of near miss events. Introduction of elements of high reliability organizations, as well as Crew Resource Management principles and communication techniques Quality Improvement indicator structure for improvement measures Simulation training lab and obstetric emergency drill program Contact: Diana J Behling MJ, BSN, RN, Manager, Ob Right Program, Sentara Health Care; djcassel@sentara.com St Anthony North OB Quality Initiative IV Oxytocin is a drug frequently used by perinatal providers and has been recently added to the list of high-alert medications by the Institute for Safe Medication Practices. Errors involving IV oxytocin administered for labor induction or augmentation are commonly dose related and can lead to oxytocin-induced tachysystole that can have a potential harmful effect on the mother and the baby. St Anthony North Hospital Women s Services identified a heightened risk for potential patient injury or harm during the administration of IV oxytocin and utilized an evidence-based approach in an attempt to reduce oxytocin-induced tachysystole. The team acknowledged that clinical disagreements and frustration are common between nurses and physicians regarding titration of oxytocin, interpretation of tachysystole and when to treat this complication.

18 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S The team developed evidence-based definitions and guidelines in an attempt to standardize the administration of oxytocin, identification, and treatment of subsequent tachysystole. A multidisciplinary approach was taken to encourage and promote a perinatal team concept to oxytocin management, fostering education and dialogue amongst colleagues and peers. Audits of oxytocin compliance reflected the target goal of 95% compliance was met within the designated 180-day timeline, demonstrating a considerable reduction from the initial baseline rate of 25% oxytocin-induced tachysystole. Oxytocin compliance continues to be monitored monthly and remains high with a 7% cumulative oxytocin-induced tachysystole rate from August 2008 through January Contact: Kathy Pehanich, RNC-OB, EFM-C, RN Educator Women s Services Student Clinical Placement Coordinator, Clinical and Professional Development; St. Joseph s Hospital Health Center (Syracuse, NY) St. Joseph s Hospital Obstetric Quality and Safety Program Richard Waldman, MD, Chairman, Obstetric & Gynecology Department James Brown, MD, Chairman, MORE OB Initiative Our Obstetric Quality and Safety Program includes: 1. Our C-section Pathway which involved the patient in earlier post operative ambulation, feeding, and foley removal producing decreased incidences of paralytic illeus, DVT s, and infections while increasing patient satisfaction. 2. Code C, a multidisciplinary rapid response team for emergency C-sections, which reduced our time from decision to delivery to less than 10 minutes. In 2005, we became the first hospital in the United States to adopt Managing Obstetric Risk Effectively (MORE OB), an international program which incorporates safety practices adopted from high reliability organizations (e.g. airline industry, nuclear power companies) with evidence based research. Key concepts include: safety, communication, teamwork, mutual respect, and repetition. Learning together consists of: 1. Online instruction and testing with private feedback 2. Multidisciplinary Core Team of our own physicians, nurses and midwives 3. Workshops and Skills drills to teach and practice high risk events (e.g. forceps, shoulder dystocia) 4. Emergency drills to rehearse team responses to emergencies (e.g. hemorrhage, cord prolapse) 5. Root Cause Analysis of No Harm Events (NHE) to incorporate safer practices before a Sentinel Event can occur. Since completing the MORE OB program, we have added: Biannual workshops Monthly emergency drills Daily multidisciplinary reports Incorporation of postpartum/nursery staff

19 All participants agree with the high value of this cooperative learning and that our response to emergencies has become consistent, organized, and efficient. Policies and systems continue to be changed to promote safety first. Contact: Mary Davis, MSN, RNC, NP; Sutter Medical Center, Sacramento Perfect Handoff Patient Safety Project Sutter Medical Center, Sacramento is a regional tertiary hospital (5,500 births/year). The Perfect Handoff project focused on improving patient safety utilizing patient/family involvement during the transition of care from L&D to Postpartum. This staff-driven initiative involved nurses from L&D and Postpartum responding to patient satisfaction surveys and the NPSG # 13 (patient s active involvement in own care) and NPSG (standardized approach to hand-off communications including an opportunity to ask questions). It was designed to address environmental constraints, while moving from staff/unit-centered frustrations to patient centered strategies and solutions. Rapid cycle change, data collection and evaluation, along with administrative/cns support, were utilized to improve the hand-off process. The postpartum nurse went to L&D about minutes after delivery for bedside report with the patient/family and L&D nurse. All involved were asked their opinions and recommendations after each transfer. Patient safety steps included keeping the patient/family story current, involvement of patient/ family in their plan of care, and access to all caregivers. This project addressed all these aspects, driven by staff desiring to do what was best for patients and willing to change processes to address patient safety. Successes included 1) more input from patients re: their history, concerns, goals, 2) integration of staff and knowledge re: other unit s challenges and work flows, 3) identification/correction of errors in patient information/ goals prior to transfer and 4) creation of an interdepartmental model for patient handoffs/ safety. This project is now being implemented in other SMCS units. Contact: Mary Campbell Bliss, RN, MS, CNS; blissm@sutterhealth.org UMass Memorial Medical Center Discharging Neonates Home on Human Milk To identify upon admission women eligible to breastfeed or pump human milk for their infant and through the implementation of the educational process discharge 75% of normal nursery newborns home on breast milk to align with the Center of Disease Control Healthy People goal. Additionally, discharge 63% of neonatal intensive care newborns on breast milk to align with the Vermont Oxford Network 2 top 25% benchmark for over 700 NICU s worldwide. In 2006, a multi-disciplinary team of twenty staff members formed to address the decrease in home on human milk for all neonates within the Women and Newborn division. Through comprehensive data collection we measured: 1. Feeding preference upon admission of women for their infant(s) 2. Infant feeding methods upon discharge 3. Maternal needs via an IRB approved survey.

20 M AT E R N I T Y Q U A L I T Y M AT T E R S AWA R D A P P L I C A N T S Results: 1. An increase in staff nurses completing the data entry program for feeding preference and discharge feeding methods [60% (2006) to 98% (2008)] % of staff nurses completed a breastfeeding competency 3. Breast feeding manuals were standardized 4. Mothers support group offered bimonthly 5. Multi-language antepartum benefit of human milk teaching sheet 6. Increase in Lactation Consultant FTEs 7. Discharge home on human milk:* Normal nursery newborns: 77% NICU infants: 64% NICU infants <1500 grams: 54% 8. Mothers upon NICU admission pumped breast milk 66% (2005) to 84%* 9. Mean score of 91.5* (out of 100) for Parent Satisfaction with Breastfeeding support in the NICU via Press Ganey Patient Satisfaction tool. *Statistics reflect data available through Q3 CY U.S. Department of Health and Human Services-Public Health Services. Objectives: 16-19a, -19b, -19c, -19e. 20 Sept. 2007< 2 Vermont Oxford Network. Burlington, VT Contact: Mary L. Naples, RN, BSN, Clinical Quality Coordinator for Women and Newborns; Mary.Naples@Umassmemorial.org Virtua TLC for Moms Perinatal Depression Program is a comprehensive program of support services available to assist women with perinatal mood disorders. The program promotes early identification of women at risk of developing perinatal mood disorders through the use of prenatal and postpartum screening. This screening is available at both in-patient and out-patient obstetric and pediatric settings and is conducted pre-natally and throughout the first postpartum year. This early identification results in timely intervention, which in turn minimizes the likelihood that patients will need hospitalization. Support services are accessible to women throughout Southern New Jersey and include a telephone warmline, weekly support groups, a lending library, Happiest Baby on the Block classes and expedited access to mental health services including hospitalization for women in crisis. In 2008, over 7000 women took advantage of the opportunity to be screened, with a resulting 5% in-patient and 9% out-patient at risk identification rate. Weekly support group meetings average 150 participants per year. The warmline provides support for both patients and physicians in need of assistance and receives over 140 calls annually. In 2008, 14 women received crisis care in Virtua s Behavioral Health Unit. TLC for Moms was established in 2002, and was named Best Practice by the New Jersey Hospital Association in Virtua provided the TLC for Moms Program Manual as a template for use by other hospitals throughout the State to assist in the creation of their own perinatal depression programs. Contact: Liz Powell, MSN, RN, Director Family Health Services; epowell@virtua.org;

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22 S Y M P O S I U M S P O N S O R S A N D S U P P O R T E R S Childbirth Connection is grateful to: The Transforming Birth Fund of the New Hampshire Charitable Foundation for its generous support of this symposium and our Maternity Quality Matters Initiative. Childbirth Connection thanks our symposium partner: Jacobs Institute of Women s Health, George Washington University School of Public Health and Health Services Friend S Childbirth Connection thanks the following symposium sponsors: Pacesetter Sponsors

23 Patron Sponsors Friend Sponsors Friend Sponsors National Priorities Partners Symposium Supporters American Nurses Association Certification Commission for Healthcare Information Technology The Leapfrog Group National Committee for Quality Assurance National Partnership for Women and Families National Quality Forum Pacific Business Group on Health The National Business Coalition on Health is a Symposium Friend