“The Journey to Zero Birth Injury……” A System-wide discussion to eliminate birth injury through the use of “best” practices Fairview Health Services Meeting of Clinical Leaders March 4, 2008

“The Journey to Zero Birth Injury……” “The Challenge for Fairview leadership as we look to the future” Mark Eustis, CEO Fairview Health Services Meeting of Clinical Leaders March 4, 2008

Mission, Values, Vision… Mission To improve the health of the communities we serve. We commit our skills and resources to the benefit of the whole person by providing the finest in health care, while addressing the physical, emotional and spiritual needs of individuals and their families. We further pledge to support the research and education efforts of our partners, the University of Minnesota, and its tradition of excellence. Values Dignity Integrity Service Compassion Vision To be the best health care delivery system in America, in partnership with University of Minnesota. Who we areWhy we exist Where we are going

Goal #2: Exceptional patient and family experience Goal #4: Strategic growth Goal #1: Exceptional clinical care Goal #3: Effective and efficient use of resources Goals VISION To be the best health care delivery system in America, in partnership with University of Minnesota.

Goals in detail… Goal #1: Exceptional clinical care Goal #2: Exceptional patient and family experience Goal #3: Effective and efficient use of resources Goal #4: Smart growth Care that is safe, effective, patient centered, efficient, timely, equitable Defined by clinicians Outcomes of care Evidenced based Reduce variation Safe, effective care Coordinated, efficient processes – convenient; administrative efficiency; comfortable environment Emotional and spiritual support – compassionate, respectful care; responsive; communication; empowerment Economies of scale Eliminate waste and redundancy Simplify, standardize and automate Staffing to demand Management structure Reduce utilization Clinical growth strategies Optimize current business and products Expand access to services/programs New/expanded business and products Increased market share in selective services

Why do we want to embark on this journey? “Right Thing To Do” for our patients and families –Birth trauma is emotionally devastating to families –Eliminating preventable birth trauma is the “ultimate outcome” of the care we provide Birth trauma is equally devastating to our staff and physicians Long-term cost to providers, families and society is reflected in the enormous cost of litigation and recovery –Impacts availability of physicians willing to perform OB services –Increased c-section delivery rates

Why do we want to embark on this journey? - continued Recognition and anticipation of known risk factors associated with the majority of preventable perinatal harm can potentially avoid birth trauma Evidenced based clinical practice exists to guide this work – Premier Perinatal Initiative, IHI Bundles, Ascension Health experience Dedicated clinical leaders and teams across the system who believe in this work Focus on “outcomes of care” and transformational thinking about new ways of delivering care

Why do we want to embark on this journey? – cont. Work we’ve already done supports this work –Culture of teamwork and high reliability teams –Team STEPPS –In Situ Simulation –Sharing of best practice Collaborative opportunity through Premier/AEIX Perinatal Safety Initiative – “we are not alone” System-wide resources to provide infrastructure support (data collection, analysis, interpretation) Set the stage for others to do similar work - use experience as “pilot” for other work

“The Journey to Zero Birth Injury……” “ The Science of evidence based practice- the why behind the how” Dr Dan Landers, Division Head of Perinatology Fairview Health Services Meeting of Clinical Leaders March 4, 2008

Patient Safety Initiatives Improve Patient Safety Improve Perinatal Outcomes Reduce Medical Errors It’s the “right thing” to do

Improving Outcomes Evidence-Based Medicine Guidelines Failure Mode Effects Analysis (FMEA) Decision Analysis Event Root Cause Analysis

Evidence-Base Medicine Based on the strength of the evidence Helps Standardize Practice A sound basis for practice guidelines Assists in the development of order sets Reduces individual/institutional liability Protects the individual in litigation

Perinatal Efforts We have begun to system-wide efforts in obstetrics Order Sets Practice Guidelines We need your support We want your participation

“The Journey to Zero Birth Injury……” “ The Opportunity: Local, System & National Initiatives” Dr Stan Davis, Quality Medical Consultant, Southdale Hospital Fairview Health Services Meeting of Clinical Leaders March 4, 2008

“We hold these truths to be self-evident, that all Men are created equal…”

But what about babies?

Addressing a “Low Frequency” BUT “High Severity” Problem A “blind spot” to the need for change may arise due to the few bad OB outcomes any one person sees in a career * 1 bad brachial plexus injury per 33 years of practice (assuming 140 deliveries per year by physician) 1 hypoxia-related case of CP per 48 years 1 case of asphyxia from VBAC uterine rupture per 403 years * Journal of Maternal-Fetal and Neonatal Medicine :203 (study of 407 Ob claims (1999 to2003) arising from 389,255 births) 18

“Be so good, they can’t ignore you…” Born Standing Up The Journey to Zero Birth Injury

Steve Martin Post-Show Routine Scrupulous records documenting what went well Also what went poorly How to make the show better next time Stayed away from drugs

Communication

Standardize

University of Minnesota Cloning Project Pediatrician PrototypeObstetrician Prototype

How to make the show better… Measurement Self-Reflection / Team-Reflection Standardization Training and Communication

Self-Reflection and Culture Change

What we’ve done so far… …the local initiatives Partnership Committee Order Sets NICHD Language TeamSTEPPS In-Situ Simulation “Red Rules” Southdale

What we’ve done so far… …the system initiatives Order Sets/Policies/Procedures TeamStepps In-Situ Simulation Steering Committee for Fetal Monitoring and Archiving to Replace BirthNet “Safest in America”

Got Blood

Premier/AEIX Perinatal Safety Initiative What we’re doing… …the national initiative …

30 Objectives of the Initiative Develop, implement and measure best practices designed to improve the reliability of perinatal care Improve clinical outcomes/patient satisfaction in L & D Lower the cost of care and potential liability exposure Build on knowledge gained through the Premier/IHI Perinatal Collaborative of , and others Enable and support the “Participating Hospitals” to:

31 Objectives of the Initiative Build High Performing Teams! Enable and support the “Participating Hospitals” to:

32 Participating Hospitals Akron City Hospital Akron, OH John C. Lincoln North Mountain Hospital Phoenix, AZ Baptist Hospital East Louisville, KY Methodist Medical Center of Illinois Peoria, IL Baystate Medical Center Springfield, MA Presbyterian Hospital Albuquerque, NM Fairview Ridges Hospital Burnsville, MN Texas Health Presbyterian Hospital of Dallas Dallas, TX City Hospital Martinsburg, WV St. Joseph Hospital Bellingham, WA Group Health Central Hospital Seattle, WA Univ. of Minnesota Medical Center, Fairview Minneapolis, MN Texas Health Harris Methodist Fort Worth Hospital Forth Worth, TX Bethesda North Hospital Cincinnati, OH Indian Path Medical Center Kingsport, TN West Allis Memorial Hospital West Allis, WI

Face-to-Face All Team meeting April 2008 –Communication techniques (SBAR, and other communication techniques for hand-offs, etc.) –Teamwork skills (situation monitoring, brief, huddle, feedback, assertion, etc.) –Obstetrical emergency situation drills or simulations (conducting, debriefing, etc.) Electronic Fetal Monitor interpretation training using NICHD criteria –HealthStream web-based training program-7 modules of self-paced training Second Face-to-Face All Team meeting Oct 2008 (6 team members) –Storyboards - sharing resources on process improvements Implementation Phase (April 2008 – Dec 2008) Training & Implementation 33

Ongoing monthly webinar and/or conference calls with teams; educational topics to include shoulder dystocia, patient flow on the L&D unit, and Risk Management’s role in the first 48 hours following unexpected outcomes Implement evidence-based “Bundles”: Submit data on metrics monthly using extranet site Periodic scorecards provided to system CEOs about team performance 34 Implementation Phase (April 2008 – Dec 2008) Training & Implementation (continued)

The Oxytocin Bundles Augmentation Bundle  Documentation of estimated fetal weight  Reassuring fetal status  Pelvic exam prior to the start of Oxytocin  Recognition and management of hyperstimulation Elective Induction Bundle  Gestational age ≥ 39 weeks  Reassuring fetal status  Pelvic exam prior to the start of Oxytocin  Recognition and management of hyperstimulation 35

Does The Implementation of Bundles Work? In 2007 Ascension Health (Seton Hospital) published an improvement of 85% in reducing frequency of birth trauma from 2 per 1,000 births to.3 per 1,000 births. Dropped to 0 elective inductions < 39 weeks. Intermountain Healthcare (2007) reported fewer injuries and complications following introduction of a “39 weeks” rule for inductions, estimating a savings of $2 million in a few short years. Charles F. Kettering Memorial Hospital reported a 69% reduction in Special Care Nursery admissions as a result of implementing the induction and augmentation bundles from participation in Premier, IHI and Ascension’s Perinatal Innovation project. 36

Consultants and Vendors Research and statistical support - Univ. of MN School of Public Health Dr. William Riley, Dr. Ira Moscovice, and other staff (as needed) Electronic Fetal Monitor Education – HealthStreams Advanced Fetal Monitor Program – 7 Modules includes CME/CEU credits Physician thought leader - Larry Veltman, MD, FACOG, Former Medical Director, author, former Chair of the ACOG Medical Liability Committee OB nursing consultant - Kristine Larison, RNC, BSN, MBA, nurse manager, Six Sigma Green Belt and author of articles on SBAR and simulation On-site assessment, project readiness evaluation and baseline data gathering- PIMS Risk Management Staff and Premier Consulting Solutions Consulting staff Defense attorney - Russell W. Schell with Schell, Mitchel & Cooley, L.L.P. Simulation and team building training – Fairview Health Systems and Univ. of MN School of Public Health; Dr. Stan Davis, Kristi Miller, RN, MSN, Dr. William Riley 37

What’s Missing from Prior OB Initiatives?  Metric Issues  No standard data set of OB harm metrics  No subset focused on neurological injury  None focused on claims, incidents, or defensibility of care  Disparate definitions (e.g. “NICU admission”) preclude benchmarking  None have explored total cost savings from improved care (although Intermountain Healthcare says it saved $1.4 million)  No consistent national data set or IT platform  Many metrics not tied to improved outcomes or providing enough information to guide further care adjustments  Methodology Shortfalls  No focus on liability issues (identification and response)  Only IHI has a patient satisfaction/care-centered focus  No measure of participants opinions on effectiveness of training  No evaluation of staffing efficiencies  No supply chain evaluation (cost of drugs and devices)  Lack of advice on physician engagement  Lack of follow-up articles to discuss long term results  Statistical rigor has not been applied in all of the studies to tell us exactly what happened and why

39 Project Metrics Outcome Metrics – Administrative Data obtained from the hospitals by NPIC Patient Safety Indicators (PSI’s) Adverse Outcome Index (AOI) Add’l administrative ICD-9 coded data Process Metrics – Data provided by Teams Bundle assessment data (induction, augmentation and devices bundles) Unit Birth Log data Survey data (AHRQ Culture of Safety, Team Satisfaction) Scorecard Metrics – Aggregation by Premier of Participant data Participation Bundle component improvement Outcomes improvement

Birth Injury % Fairview Hospitals (PSI 17) 2004 – Sept. 2007

“During this hospital stay, did your doctors treat you with respect, listen carefully, and explain things in a way you understood?”

INITIATIVE and ACRONYM OVERLOAD (IAO) Syndrome characterized by… –Bloat –Sloth –Disinterest –Generalized loathing of Administration Often seen in… Physician Lounge / Nurses Lounge

“We hold these truths to be self-evident, that all Men are created equal…”

Questions?

“The Journey to Zero Birth Injury……” “Discussion: Fairview goals and options ” Kristi K Miller RN, MS, System Director of Clinical Safety Fairview Health Services Meeting of Clinical Leaders March 4, 2008

System wide infrastructure to support the effort Decision making Accountability with local ownership Set the standards & expectations Evidence based clinical practice: Premier OB Initiative IHI Bundles Policy & Ordersets NICHD language Culture of Teamwork and High Reliability TeamSTEPPS In Situ Simulation Journey To Zero Birth Injury

Discussion What could you do at your site in –The next week –The next 3 months –The next 18 months to get to “zero birth injury”?

Discussion What could we do together as a group of physicians/nurses/executives in –The next week –The next 3 months –The next 18 months to get to “zero birth injury”?

Discussion SWOT analysis from a local and system point of view to get to “zero birth injury”? –S trength’s –W eakness’s –O pportunities –T hreats to success

Discussion What does your team envision as the best process we can do to operationalize (“make happen”) the opportunities you have heard tonite?

Thank you!