A Collaborative Model for Maternity Care Christine Pecci, MD Mari Bentley, MD Miriam Hoffman, MD Boston University Annual STFM Conference April 2007

Objectives Describe how a collaborative model improves patient safety Describe new Labor and Delivery model at Boston Medical Center Identify barriers that prevent collaboration Review some strategies in addressing these barriers Describe how a collaborative model may impact residency and medical student education

“A Birth Crisis” Nusbaum MRH, Helton MR Fam Med 2002 Emotions described by a family doctor after a fetal death: “For the next 48 hours, I experienced feelings similar to those reported by women who have been raped. There is the trauma from the event itself but then the system assaults further, leaving deep emotional scars”

“ A crisis in maternity services… Youngson R, Wimbrow T Qual Saf Health Care 2003 “The midwife was concerned about fetal well being... Experience had taught her that calling the OB would lead to immediate c/s. After another ½ hour…prolonged decel. OB was called. Consent forms thrust at mother, she refused to sign. MW and OB exchanged angry words. The mother, hysterical with pain and fear, consented to general anesthesia and surgery. A healthy baby was delivered.”

Why should we collaborate?

Medical Errors Not often the result of incompetent or negligence Usually reflection of system deficiencies We need a blameless culture Patient Safety and Quality Improvement Act of 2005 signed July 2005 protects information in quality improvement committees

Boston Medical Center Teaching hospital for Boston University 547 beds 8 Labor and Delivery rooms 2295 deliveries (2005) 2511 deliveries (2006) 2624 projected deliveries (2007)

Insurance types – OB Patients 86% Medicaid (BMCHP, NHP) 8% HMO (Tufts, Harvard Pilgrim, HMO Blue) 1% Free Care 1% Medicare 4% other, commercial insurance

Obstetrics Providers 15 Family Medicine attendings 15 OB/GYN attendings 12 Midwives 18 Family Medicine residents 12 OB residents

Old Model 3 distinct services FM attendings not required to be in-house One OB attending in-house 24/7 One OB attending backup not in-house One midwife in-house Residents worked with MDs but midwives managed patients on their own Patients were admitted to the provider who provided their prenatal care. Patients transferred to OB service if indicated

Rationale for Change Projected increase in deliveries required additional personnel (in-house) Who will that be? FAMILY MEDICINE Opportunity to create a well rounded team of L&D providers (medical+surgical) Opportunity for volume for FM attendings Opportunity for FM attendings to influence culture on L&D Finances

Process of Collaboration Weekly collaborative meetings (1 hour) OB FM MW Nursing OB resident

Mission Statement To provide safe, high quality, patient centered care all the time. 10 principles were developed to foster a collaborative working environment

Principles of a Collaborative Labor & Delivery Team of Excellence and Patient Safety at Boston Medical Center Team focused Clarity of responsibility Citizenship Acceptable case load Maximize continuity Frequent communication Good documentation High efficiency Evidence based care Excellence in education

Implementation of Model Presentation of model to stakeholders Training and education of all attendings for: Covering triage Electronic order entry Electronic H&P FM attendings in-house 24/7 with salary compensation

Evaluation Assessment of understanding and attitudes towards model (in progress) Understanding 4.33 (1-5) Effect on patient safety 2.89 (1-3) Attitude towards the model 2.45 (1-3)

Impact on Education FM maternity care providers as role models Residents and students FM faculty delivering babies are essential in influencing future practice patterns FM residents Students Consistent presence of FM residents on L&D

More Positive Changes Improved relationship between FM and OB attendings Increased role and visibility of FM attendings Culture encourages shared responsibility of all patients Overall better communication FM OB provider group has become a real team FM attending skills improved

Works in progress New dynamics between family medicine, OB and midwives Are we being truly collaborative? Do we need to redefine some of our principles? Are we keeping our identity as family physicians?

Can we change our culture?

MORE OB Program Managing Obstetrical Risk Efficiently Program that helps develop a team model Cultivates culture of trust, respect, continuous learning Society of Obstetrician and Gynecologists of Canada

Managing Obstetrical Risk Efficiently (MORE OB) Principles Safety is the priority and everyone’s responsibility Operations are a team effort Communication highly valued Hierarchy disappears in emergency Emergencies rehearsed Multidisciplinary review of routine processes

“…the courage to be wrong” Youngston, R day workshop led by outside facilitator clinics/OR cancelled; locums hired to cover Role Play to explore interactions, behaviors, beliefs, difficulty in communication Monthly multidisciplinary mtgs established Collaborative solutions Quality improvement team Protocols developed c/s rate decreased from 27% to 15% Pt complaints decreased from 9 to 2 per quarter

Summary: Collaborative Model Blameless environment is key to patient safety Involves ongoing WORK and effort Regular communication and evaluation of process important FM has opportunity to contribute our strengths to maternity care May help FM with volume/skills May enhance resident/medical student education and role modeling

Future at Boston Medical Center Further issues to be defined by results of our survey of the new model Development of a postpartum/newborn family medicine service involving collaboration with midwives and pediatricians and the creation of a unified system of care for mom/baby dyad

GROUP DISCUSSION Do you think that a collaborative model improves patient safety? What is your model of care on L&D? Does FM have a collaborative relationship with OB/GYNs and midwives? What barriers prevent a collaborative working relationship at your institution? How would a collaborative model impact the training of your residents?