Road Map to a Perinatal Patient Safety Program

Transcription

1 Road Map to a Perinatal Patient Safety Program Perinatal Safety 2012 Minnesota Hospital Assoiation

2 The Perinatal Patient Safety Road Map provides evidene-based reommendations/standards for Minnesota hospitals in the development of a omprehensive Perinatal Safety Program whih inludes strategies in the following areas: patient eduation, eletive delivery, fetal/uterine assessment, operative vaginal delivery, maternal/ obstetri morbidity and mortality redution, trial of labor after a previous Caesarean setion and provider/nurse training. The road map and aompanying tool kit were developed as part of the Minnesota Perinatal Safety Program whih was made possible with funding through CMS Partnership for Patients (P4P) Initiative. We would like to thank the following individuals for sharing their time, expertise and stories whih made the road map and tool kit possible. Planning Group Members Carol Busman, HealthEast Care System, St. Paul Stanley Davis, M.D., Fairview Health Servies, Minneapolis Jan Maxfield, Rie Memorial Hospital, Willmar Patriia O Day, M.D., Essentia Health, Duluth Sandra Hoffman, Allina Health, Minneapolis Nany Struthers, M.D., Allina Health, Minneapolis Kristi Miller, Fairview Health Servies, Minneapolis Julie Thompson Larson, HealthPartners, St. Paul Barbara Hyer, M.D., HealthPartners, St. Paul Penny Beattie, CentraCare Health System, St. Cloud Nathan Lee, M.D., CentraCare Health System, St. Cloud Medial Group Fritz Ohnsorg, Minnesota Department of Human Servies, St. Paul Tania Daniels, Minnesota Hospital Assoiation, St. Paul Mikey Reid, Minnesota Hospital Assoiation, St. Paul Kattie Bear-Pfaffendorf, Minnesota Hospital Assoiation, St. Paul 2012 Minnesota Hospital Assoiation

3 Road Map to a Perinatal Patient Safety Program Perinatal Safety Safe from HAI Speifi Ations(s) Audit Questions Yes No S Safety Teams and Organizational Struture 1) Seure endorsements and resoures for Perinatal Patient Safety Program. 2) Promote Perinatal Patient Safety Program representation hampions throughout the faility. 1a) The faility s physiian and administrative leadership endorse implementation and sustainment of the Perinatal Patient Safety Road Map praties. 1b) Senior leadership has learly ommuniated overall goals for the program. 1) Senior leadership regularly reviews progress toward goals and supports adding resoures as appropriate. 1d) The faility has a designated senior leadership sponsor for the Perinatal Patient Safety Program. 2a) The faility has an interdisiplinary team (this ould be an existing ommittee/team) involved in implementing the Perinatal Patient Safety Program with representation from aross the faility. 2b) The faility has a designated oordinator(s) for the Perinatal Patient Safety Program. 2) The oordinator(s) has designated time to serve in this oordination funtion. The faility has a proess in plae to designate members as the Perinatal Patient Safety Program hampions/team members/liaisons with lear roles and expetations from the following: 2d) Physiian(s)/provider(s) knowledgeable in obstetris 2e) Perinatal nurse(s) Additional team members an inlude, but are not limited to: 2f) Other liniians/providers, e.g., pediatris, anesthesia, surgeons, intensivist. 2g) Safety/Quality/PI 2h) Pharmay 2i) Blood bank/lab 2j) Obstetri surgial staff 3) Identify gaps and develop ation plans. 2k) The faility has a proess in plae to engage other team members as regular or ad-ho members as appropriate, e.g., purhasing, eduation, human resoures and patient/family. The interdisiplinary team: 3a) Reviews the Perinatal Patient Safety Program throughout the year and updates the plan as needed. 3b) Reviews data results at least quarterly and identifies strengths and opportunities. 3) Develops a plan to prioritize and address improvement opportunities. Page 1 Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation

4 A Aess to Information 1) Trak progress on proess and outome measures. 3d) Commissions subgroups as needed to address priority issues requiring subjet matter experts, e.g., pharmay, respiratory, environmental servies. Data Colletion A proess is in plae to ollet perinatal proess data for the following as appliable: 1a) Use and ompletion of standardized tool to shedule deliveries. 1b) Review of all Early Eletive Deliveries (EEDs) not meeting exlusion riteria. 1) Progress on Perinatal Gap Analysis praties. A proess is in plae to ollet Perinatal Outome measures for the following, at minimum: 1d) Number of EEDs not meeting exlusion riteria. N/A: 1e) Low risk vertex singleton in first time mothers. N/A: 1f) Outome data is traked on a regular basis for other areas as appliable. N/A: 1g) Standard riteria exist for onduting observational and/or hart audits. 1h) A proess is in plae to audit the reliability of both the proess and outome data through hart audits. 1i) A proess is in plae to audit the reliability of both the proess and outome data through observational audits. 1j) The faility s doumentation system (eletroni or paper) is designed to apture suffiient detail about Perinatal Patient Safety Program events that do our to allow for adequate event analysis. 2) Review and analyze data for improvement opportunities. Data Analysis 2a) A proess is in plae to routinely review and analyze data for proess improvement opportunities/defets. 2b) A proess is in plae to trak progress against established targets e.g., run harts, ontrol harts, dashboards, soreards. 2) A proess is in plae to prioritize and at upon identified issues. 3) Data is shared on a regular basis to promote systemwide learning and transpareny. Perinatal Patient Safety Program data and learnings are shared on a regular basis: 3a) Within units 3b) Aross units 3) With leadership 3d) With medial staff 3e) With the board(s) 3f) Perinatal Patient Safety Program events are routinely shared through stories as well as through data, e.g., inlude in daily briefings, units staff meetings, safety ommittees. Page 2 Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation

5 F Faility 1) Leadership establishes Expetations and ommuniates lear expetations. 2) Provide eduation for health are personnel and presribers. 3) Establish a strutured ommuniation proess. 4) Dislose unantiipated events. 1a) Diret patient are staff, e.g., nursing, physiians, respiratory therapy is informed of expetations and performane standards regarding their role in Perinatal Patient Safety Program. 1b) Support staff, e.g., environmental servies, supply hain, failities/operations, is informed of expetations and performane standards regarding their role in Perinatal Patient Safety Program. 1) The faility has a well defined proess to support a ulture that enourages staff to speak up and stop the line to inform eah other of non-ompliane with the Perinatal Patient Safety Program expetations. 1d) The stop the line proess learly outlines: When to stop the line; How to stop the line, e.g., I need larity ; The hain of ommand to follow if not supported in stopping the line; Clear ommuniation to staff from managers and leadership that staff will be supported if they speak up. 2a) Expetations and supporting Perinatal Patient Safety Program eduation have been inorporated into new employee orientation for diret are staff. 2b) Expetations and supporting Perinatal Patient Safety Program eduation have been inorporated into new employee orientation for support staff. 2) Ongoing Perinatal Patient Safety Program eduation is provided to diret are staff at least annually. 2d) Ongoing Perinatal Patient Safety Program eduation is provided to support staff at least annually. 2e) Expetations and supporting Perinatal Patient Safety Program eduation have been inorporated into employee orientation for personnel employed by outside agenies and ontrated personnel. 2f) Ongoing Perinatal Patient Safety Program eduation is provided for providers and ageny staff at least annually. 2g) Expetations and supporting Perinatal Patient Safety Program eduation has been inorporated into new physiian orientation. 3a) The faility has strutured ommuniation tools, e.g., Situation, Bakground, Assessment, Reommendation (SBAR),for ommuniation at all levels of the organization. A strutured hand-off proess is in plae throughout the organization with speifi elements outlined that must be inluded for hand-offs: 3b) During shift-hange 3) Between departments/units 3d) To other failities A proess is in plae to promptly inform families when an unantiipated perinatal patient outome ours and inludes, at a minimum: 4a) Diretion on who should disuss the unantiipated outome with the patient/ family and how that disussion should our. 4b) A proess for dislosing to, and updating, patient/ family as the event is reviewed and analyzed. Page 3 Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation

6 4) Staff members reeive training on when and how to dislose unantiipated outomes. 4d) A designated person is available to provide support and just-in-time training to staff members who are about to dislose an unantiipated outome to a patient/family. E Engagement of Patient and Families 1) Eduate and empower patient/ families. 1a) A proess is in plae to assess and address any barriers to patient/family ability to understand their role in the Perinatal Patient Safety Program (e.g., ultural, language, hearing impairment and health literay). 1b) Patients/families are eduated on their role in the Perinatal Patient Safety Program and what they an expet to see from staff and providers aring for them in the hospital, e.g., identifiation before lab draw or med administration, hand washing. 1) A proess is in plae to assess patient/families level of understanding of the eduation provided, e.g., teah bak. 1d) The faility has a proess in plae to enourage patients and families to speak up if they have onerns about diret are/support staff/provider praties or other issues that may inrease the risk for an unantiipated perinatal patient outome. 1e) A proess is in plae to report bak to patients/ families that have shared a onern. Page 4 Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation

7 Perinatal Injuries Gap Analysis Component of the Perinatal Safety Roadmap Perinatal Safety Speifi Ation(s) Gap Analysis Questions Yes No Patient Eduation If answered question No identify the Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 1) Provide patient/family eduation. 1a) The faility has a proess in plae to provide information to the patient about risks, benefits and alternatives for maternal intrapartum proedures. 1b) The faility has a proess in plae to eduate the patient and/ or family about newborn sreening per the Department of Human Servies (DHS). Eletive Delivery 2) Sheduled indution and/ or Caesarean. 2a) The faility has a hard stop poliy in plae to prevent eletive deliveries < 39 weeks without medial indiation. The faility s praties inlude at minimum: 2b) Medial indiations for sheduled delivery are defined. 2) Hospital staff is authorized to not shedule an eletive delivery before 39 weeks and 0 days of gestation. 2d) Providers are required to obtain approval from physiian leadership before performing an eletive sheduled delivery before 39 weeks. The faility utilizes the following riteria to establish gestational age for all eletive deliveries: 2e) Ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater. 2f) Fetal heart tones have been doumented as present for 30 weeks by Doppler ultrasonography. 2g) It has been 36 weeks sine a positive serum or urine human horioni gonadotropin pregnany test result. 2h) The faility has a proess in plae to doument both gestational age and medial indiations for delivery as a prerequisite to shedule delivery prior to 39 weeks. 2i) The faility has developed and maintains a list of medial indiations for delivery prior to 39 weeks. 2j) The faility has aepted the following list of evidene and onsensus based medial indiations for delivery prior to 39 weeks. The faility should not be limited to this list; additional riteria an be added using evidene and expert opinion based on pratie. Indiations inlude, but are not limited to the following: Fetal indiations Growth restrition Fetal anomalies Multiple gestation Fetal demise Isoimmunization Abnormal fetal testing Obstetri indiations Plaenta abnormalities; previa, abruption Previous uterine surgery (lassial C-setion, myometomy) Amnioti fluid abnormalities PROM Maternal indiations Hypertensive disease Diabetes Lupus Renal disease Pulmonary disease Liver disease Coagulation defet Page 1 Perinatal Injuries Component of the Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation

8 Speifi Ation(s) Gap Analysis Questions Yes No If answered question No identify the Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 2j) The faility has a quality improvement proess in plae to review all deliveries less than 39 weeks, for appropriateness of the medial indiations. Fetal/Uterine Assessment 3) Estimated fetal size Fetal heart rate 3a) The faility requires that all patients have estimated fetal size doumented prior to delivery. 3b) The faility requires that the fetal heart rate assessment is doumented in the medial reord using the National Institute of Child Health and Human Development (NICHD) terminology. 3) The faility has a poliy in plae that outlines the appropriate and safe administration of uterotonis relative to fetal heart rate assessment. 4) Pelvi exam 4a) The faility requires provider/rn do a vaginal exam and doument dilatation, effaement, station, presenting part prior to the indution/augmentation as linially appropriate. 5) Uterine ontrations 5a) The faility has standard praties in plae for the appropriate and safe administration of uterotonis relative to uterine ontrations. 5b) The faility has standard praties in plae for doumenting uterine ativity in the medial reord using the National Institute of Child Health and Human Development (NICHD) terminology. 5) The faility has standard praties in plae for the management of abnormal uterine ontrations. Operative Vaginal Delivery 6) Operative Vaginal Delivery 6a) The faility has standard praties in plae for appropriate and safe performane of operative vaginal delivery. The guidelines may inlude: alternative labor strategies, prepared patient, high probability of suess, maximum number of appliation and pop-offs predetermined, exit strategy available, ommuniation and doumentation with infant aregivers about use of operative vaginal delivery. 6b) The faility has a quality improvement proess in plae to review operative vaginal deliveries that fall outside the faility s standard praties. Maternal/Obstetri Morbidity and Mortality Redution Strategies 7) Management of Hypertensive Emergenies 7a) The faility has a proess in plae for assessment and management of hypertensive emergenies whih inlude blood pressure parameters and mediation regimen, e.g., standard order sets or protools. 8) Postpartum hemorrhage 8a) The faility has a proess in plae for assessment and management (medial/surgial/mehanial) of postpartum hemorrhage whih inludes risk assessment and management of the patient, staff reognition and response, e.g., standard order sets and mediation regimen. 8b) The faility has a plan for management/transfusion/transfer for the patient with massive blood loss, e.g., massive transfusion protool, inter-faility transfer guidelines, surgial options, uterine tamponade balloon. Page 2 Perinatal Injuries Component of the Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation

9 Speifi Ation(s) Gap Analysis Questions Yes No If answered question No identify the Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 9) VTE prevention 9a) The faility has a proess in plae for assessment and management of VTE prevention whih inludes mehanial prophylaxis for all C-setions, unless ontraindiated and pharmalogial interventions as appropriate, e.g., SCIP protool. 10) Perioperative infetion prevention strategies 10a) The faility has a proess in plae for routine administration of appropriate weight based pre-operative antibiotis within 1 hour prior to inision, e.g., pre-op order set. 11) Minnesota Maternal Mortality reporting requirement 11a) The faility has a proess in plae to ensure awareness of and ompliane with the Minnesota Maternal Mortality reporting Statute # among hospital Quality, and Obstetri and Emergeny Department providers. Trial of Labor after Previous Caesarean Setion 11) Trial of labor after previous Caesarean 11a) The faility s proess for possible vaginal births after Caesarean delivery (VBAC) inludes ounseling and offering a trial of labor (whih should inlude referral to another hospital) after previous Caesarean delivery (TOLAC). 11b) The faility has a proess in plae for appropriate and safe administration of uterotonis relative to TOLAC whih inludes no third trimester prostaglandins. Provider and Nurse Training 12) Provider and staff eduation The faility provides periodi interdisiplinary eduation whih inludes: 12a) Eduation for providers and nurses on eletroni fetal monitoring using the National Institute of Child Health and Human Development (NICHD) ommon language. 12b) Maternal/newborn team risis training on issues suh as: shoulder dystoia, Postpartum hemorrhage, emergeny delivery, newborn resusitation, hypertensive emergeny. 12) Training on individual ommuniation skills and team ollaboration, e.g., SBAR, TeamSTEPPS, briefs, debriefs, handoffs, simulation. Page 3 Perinatal Injuries Component of the Road Map to a Perinatal Patient Safety Program 2012 Minnesota Hospital Assoiation